Abstracts - American Academy of Ophthalmology

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					Reviewer note:
The following documents are from the initial review round of the 2011 American
Glaucoma Society Annual Meeting gap analysis. These are not the final
documents used in CME approval. References and citations will require an
explanation of relevancy to a different target audience and will likely require
clarification (as did many of these in abstracts in their original submission)


Abstract.ControlNumber:139

Abstract.Title:Corneal Hysteresis Predicts The Magnitude Of Intraocular Pressure Reduction From
Topical Prostaglandin-Analogue Therapy

PrimaryAuthor.AuthorBlock:

Joshua R. Ehrlich, Daniel R. Agarwal, Mitsugu Shimmyo, Nathan M. Radcliffe. Weill Cornell Medical
College, New York, NY, New York Eye and Ear Infirmary, New York Medical College, New York, NY

Topic.Topic1:Other

Abstract.Abstract1:

Introduction: Corneal hysteresis (CH) is a risk factor for glaucoma progression but may be influenced by
intraocular pressure (IOP) [1,2]. We sought to evaluate the association between baseline CH and the
magnitude of IOP reduction among treatment naïve eyes treated with topical prostaglandin-analogues
(PGA).
Methods: In this retrospective study, 61 consecutive patients with newly diagnosed open angle-
glaucoma (OAG) who were initiated on IOP lowering therapy with a PGA from an untreated baseline
were reviewed. Included patients underwent ORA measurement (Reichert, Corp., Buffalo, NY) at
baseline (untreated) and during a subsequent follow-up (treated) visit. Patient records were reviewed
for demographic, medical and ocular data.
Results: Goldmann-correlated IOP measured by ORA was reduced by 4.0 mm Hg (22.3%) from 17.9 mm
Hg at baseline to 13.9 mm Hg (P<0.001). Corneal hysteresis increased by 0.6 mm Hg (6.3%) from 9.5 mm
Hg to 10.1 mm Hg (p = 0.002). Baseline CH (but not baseline CCT) was a significant predictor of the
magnitude of IOP response, with patients in the lowest quartile of CH (mean 6.9 mm Hg) experiencing
32.1% IOP reduction while those in the highest CH quartile (mean 11.9 mm Hg) experienced 7.6% IOP
reduction (P<0.001). Since baseline IOP differed between CH quartiles, a multivariate analysis adjusting
for baseline IOP was performed that demonstrated that baseline CH independently predicts the
magnitude of percent IOP reduction from topical therapy (ß=-3.5, 95% confidence interval -6.2, -0.7,
p=0.01).
Discussion: CH may be a valuable tool in prognosticating the anticipated response to topical PGA
therapy among patients with OAG and these findings may have implications for clinical trial design.
Conclusions:Although CH is influenced by IOP, baseline CH is independently associated with the
magnitude of IOP reduction from topical PGA therapy.
References:
1. Congdon NG, et al. Am J Ophthalmol. 2006;141:868-75.
2. Sun L, et al. Am J Ophthalmol. 2009;147:1061-6.

Abstract.ControlNumber:140

Abstract.Title:Mid-term Results Of Efficacy, Safety, And Survival Rates Of PGY4 Resident Performed
Trabeculectomy With MMC Alone Or With The Ex-PRESS Shunt

PrimaryAuthor.AuthorBlock:

STELLA N. ARTHUR, Guruprasad R. Pattar, Darrell WuDunn, Mark Kaehr, Louis B. Cantor, Joni Hoop, Yara
Catoira-Boyle. INDIANA UNIVERSITY, INDIANAPOLIS, IN

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To evaluate mid-term efficacy, safety, and survival rates of trabeculectomy (trab) with
MMC alone or with Ex-PRESS shunt R-50 (trab-Ex) performed by PGY4 residents.
Methods: Retrospective chart review of consecutive trabs from 3/26/06 to 5/1/08 and trab-Ex from
5/1/08 to 2/1/10 performed by residents under supervision of single attending surgeon (YCB). Visual
acuity (VA), intraocular pressure (IOP), number of medications, steroid use in weeks, suture lysis,
incidence of choroidal effusion and hypotony were analyzed. Failure criteria were: IOP 21 mmHg or less
than 20% reduction; loss of light perception; bleb revision; or further glaucoma surgery.1
Results: 29 patients underwent trab and 22 patients had trab-Ex. Follow-up (f/u) was 27.3 ±16.7 vs.
11.8±6.9 months for trab and trab-Ex respectively (p=0.0001). 22 trab patients and 17 trab-Ex patients
had 12 months f/u. Age, ethnicity, previous surgery or laser, or lens status were similar in both groups.
Trab and trab-Ex had similar mean±SD of: logMAR VA pre-operatively (0.31±0.3 vs. 0.32±0.5, p=0.95),
and at 12 months (0.51±0.6 vs. 0.56±0.6, p=0.77); IOP pre-operatively (17.9±5.1 vs. 20.9±9.5, p=0.14),
and at 12 months (10.6±5.9 vs. 11.7±7.5, p=0.61); and medications pre-operatively (3.6±0.8 vs. 3.3±0.9,
p=0.27), and at 12 months (0.9±1.5 vs 1.3±1.7, p=0.45).
Suture lysis (40% vs. 38%) and steroid use in weeks (21.0±16.1 vs. 17.5±11.1, p=0.38) were similar in
both groups. Trab-Ex had no effusions (0% vs. 17%) or hypotony (0% vs. 18%) compared to trab. Survival
rates for trab vs. trab-Ex were 92% vs. 96% at 12 months.
Discussion: At 12 months trab had lower safety and similar efficacy and survival to trab-Ex. Our data
support the efficacy of Ex-PRESS shunt.2
Conclusion: Ex-PRESS shunt appears a reasonable option for novice surgeons. Long-term prospective
studies are needed to substantiate these findings.
Reference: 1. Gedde SJ, et al; Tube Versus Trabeculectomy Study Group. Three-year follow-up of the
tube versus trabeculectomy study. Am J Ophthalmol 2009;148:670-84
2. Maris PJ Jr, et al. Comparison of trabeculectomy with Ex-PRESS miniature glaucoma device implanted
under scleral flap. J Glaucoma. 2007;16:14-19.

Abstract.ControlNumber:147

Abstract.Title:

Altered Stability of mRNAs Associated with Glaucoma Progression in Human Trabecular Meshwork
Cells Following Oxidative Stress

PrimaryAuthor.AuthorBlock:

Hideki Mochizuki, James D. Brandt, Paul Russell. University of California, Davis, Davis, CA, University of
California, Davis, Davis, CA

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:


Introduction: Oxidative stress is present in glaucoma and may be an important factor in its
pathogenesis. Certain cytokines are increased in human trabecular meshwork (HTM) cells after
oxidative challenge. It has been reported that HuR, an RNA-binding protein, can stabilize mRNA with
an AU-rich element (ARE) in the 3’-untranslated region from degradation in the cytoplasm. The
purpose of this study is to determine if oxidative stress on HTM cells influences the stability of key
ARE-containing mRNAs known to be associated with glaucoma progression.
Methods: Cultures of HTM cells were established from several different normal donor corneal buttons
that were unsuitable for transplant. Immunohistochemistry for HuR was performed in addition to
Western blots of HuR. The cells were treated with 150μM hydrogen peroxide for 2 hours in the
presence of actinomycin D, which inhibits RNA synthesis, and compared with control cells. The
selected mRNAs from the cells were analyzed by using relative quantitative PCR.
Results: HuR was detected in HTM cells with Western blot. Immunohistochemistry demonstrated that
hydrogen peroxide treatment induces the translocation of HuR from the nucleus to the cytoplasm.
Hydrogen peroxide increased IL-6 mRNA stability 1.5 to 2 fold while IL-8 mRNA was increased 1.1 to
1.3 fold. The mRNAs of SPARC and MMP-3, which do not have AREs, were stable after actinomycin D
treatment and were not altered with oxidation.
Discussion: Oxidative stress stabilizes IL-6 mRNA significantly while IL-8 mRNA stability was marginally
increased. Our data suggests that the decay of certain mRNAs associated with glaucoma is altered in
the TM of glaucoma patients.
Conclusion: Stabilization of mRNAs may provide new insights into the pathogenesis of glaucoma and
presents the potential for development of new therapies to target the HTM.

Abstract.ControlNumber:148

Abstract.Title:
The Effect of Nasal Steroids on Intraocular Pressure in Ocular Hypertension or Controlled Glaucoma

PrimaryAuthor.AuthorBlock:

Yvonne M. Buys, Darana Yuen, YaPing Jin, Tariq Alasbali, Graham E. Trope. University of Toronto,
Toronto, ON, Canada, University of Toronto, Toronto, ON, Canada

Topic.Topic1:Pharmacology

Abstract.Abstract1:

Introduction: Approximately 18-36% of the general population are steroid responders and this increases
to 46-92% in POAG.1 Allergic rhinitis affects up to 30% of US adults.2 Topical nasal steroids are the most
effective treatment option. Studies evaluating the effect of nasal steroids in glaucoma patients are
limited.
Methods: Prospective randomized double-masked controlled trial to evaluate the effect of 6 weeks of
nasal steroids on IOP in ocular hypertension or controlled POAG. Eligible subjects were randomized to
either beclomethasone or saline nasal spray twice daily for 6 weeks. There were a total of 4 study visits;
baseline and weeks 2, 4 and 6 after starting the spray. Each study visit was at the same time +/- 1 hour.
The main outcome measure was IOP. The study received ethics approval and was registered
(Clinicaltrials.gov identifier NCT00775489). A sample size calculation indicated that 8 patients in each
arm would be required to detect a difference of 3.2 mmHg with a power of 80%.
Results: 19 subjects completed the study; 9 in the steroid arm and 10 in the placebo arm. There were no
statistically significant differences between the groups in baseline characteristics, IOP or change in IOP
from baseline at any time point. At 6 weeks the mean change in IOP from baseline was -0.44 and 0.20
mmHg in the right eye (p=0.33) and 0.72 and 0.90 in the left eye (p=0.73) in the steroid and saline
groups respectively.
Discussion: There is only one previously published study specifically evaluating nasal steroids in a
glaucoma population.3 This case-control study using claims database was statistically limited by the
small number of patients taking continuous high-dose nasal steroids.
Conclusions: OH and POAG subjects show no evidence of a steroid response following 6 weeks of twice
daily beclomethasone nasal spray.
References:
1. Tripathi RC, et al: Corticosteroids and glaucoma risk. Drugs Aging 1999;87:439-50.
2. Dykewicz MS, Fineman S: Executive summary of joint task force practice parameters on diagnosis and
management of rhinitis. Ann Allergy Asthma Immunol 1998;81:463-8.
3. Garbe E, et al: Inhaled and nasal glucocorticosteroids and the risks of ocular hypertension or open-
angle glaucoma. JAMA 1997;277:722-7.

Abstract.ControlNumber:159

Abstract.Title:Simultaneous Placement of Two Glaucoma Drainage Devices for Uncontrolled Glaucoma

PrimaryAuthor.AuthorBlock:
Anna C. Momont, Joshua D. Stein, Jennifer S. Weizer. University of Michigan, Ann Arbor, MI

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: It has been suggested that glaucoma drainage devices (GDDs) which have a larger
explant surface area provide better long-term intraocular pressure (IOP) control while the presence of
a flow restrictor or "valve" reduces the risk of postoperative hypotony while achieving immediate IOP
lowering.1 The purpose of this study is to report baseline characteristics and surgical outcomes of
placement of simultaneous GDDs in eyes with considerably elevated IOP despite maximal medical
therapy.
Methods: Retrospective case series. The medical records were reviewed of consecutive patients who
underwent simultaneous placement of a Baerveldt 350 and Ahmed S3 GDDs in the same eye at the
University of Michigan Kellogg Eye Center from 2006 to 2009. Baseline characteristics, preoperative
and postoperative IOP, number of glaucoma medications, visual acuity, and complications were
recorded.
Results: Fourteen eyes of 14 patients (mean follow-up, 14.9 ± 15.4 months) underwent simultaneous
placement of two GDDs in the same eye. The mean baseline cup to disc ratio was recorded at 0.94 ±
0.06 horizontally and 0.92 ± 0.08 vertically. The mean baseline IOP of 38.8 ± 5.7 mm Hg was
significantly reduced at all times points following placement of the GDDs, and the mean IOP at last
follow-up was 13.9 ± 5.8 mm Hg (p ≤ 0.0001)). Mean number of glaucoma medications was
significantly lower at last follow-up than preoperatively (1.5 ± 1.5 vs. 3.1 ± 0.9; p = 0.0007). There was
no difference in mean logMAR visual acuity from preoperative to last follow-up (1.05 vs. 1.07; p =
0.95).
Discussion: Simultaneous placement of a Baerveldt 350 and Ahmed S3 GDD effectively lowers IOP in
the immediate post-operative period and long-term without significant intra-operative or
postoperative complications.
Conclusions: This surgical approach may be useful in glaucomatous eyes with advanced disease and
considerably elevated preoperative IOPs.

References:
1. Minckler DS, Francis BA, Hodapp EA, et al. Aqueous shunts in glaucoma: a report by the American
Academy of Ophthalmology. Ophthalmology 2008;115(6):1089-98.

Abstract.ControlNumber:161

Abstract.Title:Enhanced Depth Imaging Optical Coherence Tomography of Deep Optic Nerve Complex
Structures

PrimaryAuthor.AuthorBlock:
Sung Chul Park, Carlos Gustavo V. De Moraes, Christopher CW Teng, Celso Tello, Jeffrey M. Liebmann,
Robert Ritch. New York Eye and Ear Infirmary, New York, NY, New York University School of Medicine,
New York, NY

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Introduction: To assess the usefulness of enhanced depth imaging spectral-domain optical coherence
tomography (EDI SD-OCT) in evaluating deep structures of the optic nerve complex (ONC: optic nerve
head + parapapillary structures).
Methods: EDI SD-OCT images were obtained from both eyes of 71 glaucoma patients. Deep ONC
structures including lamina cribrosa (LC), parapapillary choroid and sclera, short posterior ciliary
artery (SPCA) and its branches, and optic nerve meninges with subarachnoid space were investigated.
Results: LC of various cross-sectional shapes (flat, round, oblique and W-shaped) was clearly
differentiated from prelaminar tissue in most eyes, but its posterior surface was variably demarcated.
Posterior bowing of the LC in patients with unilateral visual field loss varied considerably (patient 1
[A,B] vs. 2 [C,D]), and so did its pore shape. Most eyes had 1 round pore for the central retinal artery
and 1 or 2 irregularly shaped pores for (branches of) the central retinal vein. SPCAs and their branches
including the cilioretinal artery were frequently visualized (E,F). There was a full-thickness defect of
the LC in the area of acquired pit (G) and an unspecified central pit of the optic nerve in 2 eyes,
respectively. Subarachnoid space and its trabeculae around the optic nerve was identified with optic
nerve meninges in 11 eyes with myopia (H), and an ovoid full-thickness scleral defect was noted in 1
eye with extreme myopia.
Discussion: EDI SD-OCT provided detailed high-resolution cross-sectional images of the deep ONC
structures, which can be reconstructed into 3D images.
Conclusions: EDI SD-OCT is helpful in detecting, conceptualizing and understanding basic and
complicated anatomies and pathologies of the ONC.
Abstract.ControlNumber:163

Abstract.Title:

Prospective Randomized Study Comparing Ex-PRESS to Trabeculectomy: Interim Results

PrimaryAuthor.AuthorBlock:

LILACH DRORI WAGSCHAL, GRAHAM TROPE, DELAN JINAPRIYA, YVONNE BUYS. UNIVERSITY OF
TORONTO, TORONTO, ON, Canada

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: There is only 1 prospective publication comparing guarded Ex-PRESS implantation to
trabeculectomy.1 That study reported better IOP control with the express shunt.
Methods: Prospective randomized study comparing guarded Ex-PRESS to trabeculectomy. Primary
outcomes were IOP and success (IOP between 5-18 mmHg and 20% reduction from baseline without
medication). Secondary outcomes included # glaucoma medications, complications, corneal thickness
and endothelial cell counts.
Results: To date 38 subjects have been enrolled, 19 in each group. 25 have completed 6 months and 13
have completed 1 year follow-up. At baseline, 6 months and one year the mean IOP was 24.1±7.4 vs
20.7±10.8 (p=0.26), 11.2±4.1 vs 10.8±4.7 (p=0.86) and 14.5± 4.4 vs 11.9±3.4 (p=0.25) in the
trabeculectomy vs ExPRESS groups respectively. At 6 months and one year complete success rates were
83% vs 54% (p=0.20) and 33% and 57% (p=0.59) in trabeculectomy vs ExPRESS groups respectively.
There were no statistically significant differences in # glaucoma medications, pachymetry, endothelial
cell count or complications.
Discussion: Only 2 previous publications have compared these techniques. One a retrospective study of
100 eyes found no difference in success but more hypotony and choroidal effusions in the
trabeculectomy group.2 A prospective, randomized trial of 80 eyes at 1 year found significantly higher
success in the Ex-PRESS group and no difference in complications.1
Conclusions: To date our interim results found no statistically significant difference between the
ExPRESS and the trabeculectomy groups regarding IOP and complications.
References:
1.
De Jong LA. The Ex-PRESS glaucoma shunt versus trabeculectomy in open-angle glaucoma: a prospective
randomized study. Advances in Therapy 2009;26:336-45.
2.
Maris PJ, Ishida K, Netland PA. Comparison of Trabeculectomy with Ex-PRESS miniature glaucoma device
implanted under scleral flap. J Glaucoma 2007 January;16:14-9.
Financial Disclosure: I-MED supplied 14 of the ExPRESS shunts at no cost.

Abstract.ControlNumber:164
Abstract.Title:Comparison of Surgical Outcomes Between Canaloplasty and Trabeculectomy at 12
Months Follow-Up

PrimaryAuthor.AuthorBlock:

Ramesh S. Ayyala, Amina L. Chaudhry, David Zurakowski. Tulane School of Medicine, New Orleans, LA,
Children’s Hospital Boston, Harvard Medical School, Boston, MA

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: To compare surgical outcomes of patients following canaloplasty and trabeculectomy through
12 months follow-up.
Methods: Retrospective, non-randomized, comparative case series (in patients with OAG) involving 33
eyes in 33 patients who underwent canaloplasty and 46 eyes in 46 patients who underwent
trabeculectomy with MMC with 12 months postoperative follow-up were included. All surgeries were
performed by a single surgeon.
Main Outcome Measures: IOP, visual acuity, postoperative medications, surgical failure and
complication rates.
Results: There were no differences in demographics or previous surgery between the groups. Excluding
surgical failures and patients on postoperative medications, ANOVA indicated that IOP was significantly
higher in the canaloplasty group on 1 day (P = 0.02), 1 week (P < 0.01),1 month (P < 0.01) and 12 months
(P = 0.02). No significant differences were found in the number of preoperative or postoperative
medications, or visual acuity at 12 months. There was no difference in surgical failure rates between
canaloplasty (n = 5, 15%) and trabeculectomy (n = 5, 11%) groups (P = 0.74). A higher percentage of
patients treated with canaloplasty than trabeculectomy (36% vs. 20%) required postoperative
medications, although this did not reach statistical significance (P = 0.12).
Conclusions: Canaloplasty and trabeculectomy both achieved significant reduction in IOP at 12 months,
although trabeculectomy is more likely to result in IOP closer to 10 mm Hg with fewer patients requiring
postoperative medications.
Ref: 1.Lewis RA. Von Wolf K, Tetz M. et al. Canaloplasty: Circumferential viscodilation and tensioning of
Schlemm’s Canal using a flexible microcatheter for the treatment of open angle glaucoma in adults:
Interim clinical study analysis. J Cataract Refract Surg 2007; 33:1217-1226.
2.Lin YP, Zurakowski D, Ayyala RS. Surgical outcomes of traditional limbal-based versus fornix-based
trabeculectomy with corneal valve. Ophthalmic Surg Lasers Imaging. 2007 Nov-Dec;38(6):471-477.

Abstract.ControlNumber:165

Abstract.Title:Surgical Outcomes Of DSAEK In Patients With Prior Glaucoma Drainage Device Placement

PrimaryAuthor.AuthorBlock:

Ramesh S. Ayyala. Tulane School of Medicine, New Orleans, LA
Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: To study the surgical outcomes following DASEK in patients with glaucoma and prior Ahmed
valve implantation.
Method: Retrospective chart review of 17 consecutive DSAEK procedures performed on eyes with prior
AGV placement between 2008-2010.<br
Results: 12%(2) of the DSAEK grafts experienced Primary Graft Failure (one of these had 3
dislocations).The dislocation rate was 24% with one eye with two Ahmed valves and two eyes with more
than one dislocation. Most dislocations occurred in the early part of the study with air escaping via the
valve. A new technique was developed (“air lock”) to float the graft following which we did not have any
more dislocations. The endothelial cell loss was 22.5±16.5% at 12 ±5 months. Of the 17 eyes, GDD
function was preserved in 100% with only one eye requiring 1 additional medication (0.6%) at the last
visit.
Conclusion: DSAEK surgery appears to be safe in patients with prior GDD in the 6-12 month period.
Glaucoma appears to be well controlled in patients who have DSAEK after GDD.Long term follow up and
more patient data is needed to confirm these findings.
Ref: Phillips PM, Terry MA, Shamie N, Chen ES, Hoar K, Dhoot D, Shah AK, Friend DJ, Rao NK, Davis-
Boozer DD.Descemet stripping automated endothelial keratoplasty in eyes with previous
trabeculectomy and tube shunt procedures: intraoperative and early postoperative
complications.Cornea. 2010 May;29(5):523-7.

Abstract.ControlNumber:166

Abstract.Title:Needling vs. Blebectomy: Surgical Outcomes Of Ahmed Valve Encapsulated Blebs

PrimaryAuthor.AuthorBlock:

Ramesh S. Ayyala, Arley S. Jaramillo. Tulane School of Medicine, New Orleans, LA

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose : To evaluate the surgical outcomes of poorly functioning encapsulated filtering blebs (with
poor response to topical medications) following AGV by needling with MMC vs. surgical excision.
Methods: Retrospective study of 158 Glaucoma pts. who underwent Ahmed valve implantation from
2007 to 2009.
Inclusion criteria: Failed AGVs due to encapsulated blebs with IOP > 21 mm Hg on meds. that were
managed by one or more needling with MMC or surgical excision of the capsule.
Success defined as decrease in IOP by 30% or IOP less than 21 mm Hg, maintained for at least 6 months
or longer (12-24 months).
Failure defined as IOP > 21 mm Hg on maximum medications
Results : 26 eyes of 24 patients met inclusion criteria. 18 eyes of 16 patients were treated with needling
of the bleb followed by injection of 0.05 cc MMC (0.4mg/cc).
3 patients had more than 1 needling (2-4) of the bleb.
6 patients were treated with surgical excision followed by the application of weck cell sponge soaked in
MMC (0.4 mg/cc) for 40 seconds.
No complications were noticed in terms of conjunctival melt overlying the end plate, infections , corneal
decompensation or other vision threatening events
Needling resulted in 9/18 (50%) success rate at 6 months and at 18 months. Excision resulted in 5/6
(83%) success at 6 months and 4/6 (67%) at 18 months.
Conclusion: Needling with MMC is a reasonable first option in the treatment of encapsulated blebs (not
responding to medications). Surgical excision of the encapsulated blebs with MMC application is an
excellent second option, when needling fails. Longer follow up and more patients are needed to confirm
these findings.
Ref:
1. Hong CH, Arosemena A, Zurakowski D, et al. Glaucoma drainage devices: a systematic literature
review and current controversies. Surv Ophthalmol. 2005;50:48-60.
2. Cantor LB. Filtration surgery and tube shunts, In: Gross RL (ed). Clinical Glaucoma Management,
Critical Signs in Diagnosis and Therapy. Philadelphia: W.B. Saunders; 2001:277-313.

Abstract.ControlNumber:167

Abstract.Title:

Effect of Head and Body Position on Intraocular Pressure: A Randomized Trial

PrimaryAuthor.AuthorBlock:

Mehrdad Malihi, Arthur Sit. Mayo Clinic, Rochester, MN

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Effect of Head and Body Position on Intraocular Pressure: A Randomized Trial
Introduction:
Intraocular pressure (IOP) is a dynamic process that varies with head and body position. No previous
studies have investigated the effects of such positions in a randomized fashion to eliminate the effects
of measurement sequence.
Methods:
Twenty five healthy volunteers, age 19 to 47 years (mean 28.6 ± 8.5), were recruited. IOP was measured
using pneumatonometry in six different positions (Table 1). The sequence of measurement positions
was randomized, and 5-minute intervals elapsed between positions to allow IOP to reach a steady state.
Results:
All subjects were low myopes (mean spherical equivalent: -2.6 ± 0.77 D). Sitting IOP with neck in neutral
position was significantly lower than all other positions (Table 1). IOP in neck flexion was higher than
extension (P<0.001). IOP was higher in the dependent eye in lateral decubitus positions: 18.8 ± 2.8
mmHg (OD) and 17.7 ± 3.0 mmHg (OS) in right lateral decubitus (P=0.013), and 17.6 ± 2.5 mmHg (OD)
and 18.3 ± 2.7 mmHg (OS) in left lateral decubitus (P=0.071; MDD=1.09).
Discussion:
To our knowledge, no previous study has investigated the effect of neck flexion/extension on IOP. The
IOP elevation due to neck position is likely due to venous compression and increase in episcleral venous
pressure (EVP). The dependent nature of IOP elevation with head and body position strongly suggests a
hydrostatic effect, which also may affect EVP.
Conclusions:
IOP in the sitting position with the neck in neutral position is significantly lower than other neck or lying
positions. Lateral decubitus positions results in a small increase in the IOP in the lower eye.

                                                   Table 1

                      Mean IOP of the two eyes               P-value(compared to sitting with neutral neck
Position
                      (mmHg)(± SD)                           position)

Sitting-neck neutral 14.8 (± 2.0)                            -

Sitting-neck flexion 19.7 (± 2.6)                            <0.001

Sitting-neck
                      16.4 (± 3.8)                           <0.001
extension

Supine                17.3 (± 2.9)                           <0.001

Right lateral
                      18.2 (± 2.9)                           <0.001
decubitus

Left lateral
                      18.0 (± 2.6)                           <0.001
decubitus



Abstract.ControlNumber:169

Abstract.Title:Optic Disc Hemorrhage Detection Using Automated Alternation Flicker

PrimaryAuthor.AuthorBlock:

Nathan M. Radcliffe, Zeba A. Syed, Carlos Gustavo V. Carlos De Moraes, Scott D. Smith, Jeffrey M.
Liebmann, Robert Ritch. Weill Cornell Medical College, New York, NY, Einhorn Clinical Research Center,
New York, NY, Columbia University Medical College, New York, NY, New York University, New York, NY
Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Optic Disc Hemorrhage Detection Using Automated Alternation Flicker
Abstract
Purpose/Introduction: Optic disc hemorrhages (DH) are associated with active glaucomatous
neurodegeneration and ongoing visual field loss and are the single strongest predictor of progression.1,2
We sought to determine whether automated alternation flicker (AAF) enhances the detection of DH in
serial images from glaucoma patients as compared to side-by-side photographic evaluation and single
image display.
Methods: In this retrospective cohort study, serial sets of optic nerve photographs of 394 eyes from 234
patients followed for glaucoma at the authors’ institutions were included in this study. Eyes with DH
were graded for difficulty level and randomized along with non-DH control images into one of three
presentation groups (AAF, side-by-side, or single image). Seven graders viewed all images and assessed
for the presence of absence of DH. Response times were recorded.
Results: The sensitivity of AAF for DH detection (0.878) was higher than side-by-side (0.705; p=0.002)
and single photographs (0.757; p=0.01). There was no specificity difference between pairs of
presentation groups (all p≥0.7). Mean response times using AAF (3.7 sec) were shorter than side-by-side
images (5.4 sec, p<0.0005). There were no significant differences in response times between AAF and
single images (4.0 sec; p=0.3).
Discussion: Given that the presence of DH is one of the strongest negative prognostic indicators for
glaucoma, an increased rate of detection would likely result in changes to the clinical management of
glaucoma patients.
Conclusion: AAF was a more sensitive and method for DH detection than the current clinical standards
and may have an important role in the clinical management of glaucoma.
References:
1. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: Baseline Factors
That Predict the Onset of Primary Open-Angle Glaucoma. Arch Ophthalmol. 2002;120:714-720.
2. Budenz DL, Anderson DR, Feuer WJ, et al. Detection and prognostic significance of optic disc
hemorrhages during the Ocular Hypertension Treatment Study. Ophthalmology 2006;113:2137-43.

Abstract.ControlNumber:170

Abstract.Title:The Effect of Software Upgrade on Optical Coherence Tomography Measurement of
Retinal Nerve Fiber Layer Thickness

PrimaryAuthor.AuthorBlock:

Leonard K. Seibold, Naresh Mandava, Malik Y. Kahook. University of Colorado, Aurora, CO

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:
Introduction:To determine the effect of software upgrades on retinal nerve fiber layer (RNFL)
thickness measurements taken by optical coherence tomography (OCT).
Methods:80 normal eyes (40 patients) were scanned for RNFL thickness measurements using the
Spectralis (Heidelberg Engineering, Heidelberg, Germany) spectral-domain OCT instrument by a single
experienced operator on the same day. Scan analysis was performed using version 4.0 software and
then reanalyzed after upgrade to version 5.1.3. Student paired t testing and Pearson's correlation
coefficient were used for statistical analysis.
Results:Average and quadrant RNFL thicknesses generated using version 4.0 and 5.1.3 software on
Spectralis demonstrated high correlation (r= 0.998 average, r=0.996-0.957 quadrants). Average RNFL
thickness using version 4.0 software was 107.41 µm ± 13.30 compared to 107.34 µm ± 13.13 for
version 5.1.3 software (p=0.488). Version 5.1.3 also generated thinner RNFL measurements in the
temporal and nasal quadrants. Mean quadrant RNFL differences between version 4.0 and 5.1.3 were
+0.37 µm (p=0.055) temporal, -1.15 µm (p=0.096) superior, +0.26 µm (p= 0.294) nasal, and 0.00 µm
(p=1.000) inferior.
Discussion:Recent studies have shown significant differences in RNFL measurements between
different spectral and time domain OCT instruments 1. While previous work has shown decreased
artifacts in spectral-domain compared to time-domain OCT, this to our knowledge is the first study to
evaluate for differences in RNFL thickness values due solely to software upgrades in the same device 2.
Conclusions:There is excellent correlation in RNFL thickness measurements taken with Spectralis OCT
before and after software upgrades. While the thickness values are not identical, the difference did
not reach statistical significance.
References:
1. Seibold LK, Mandava N, Kahook MY. Comparison of Retinal Nerve Fiber Layer Thickness in Normal Eyes Using Time-Domain and Spectral-Domain Optical

Coherence Tomography. Am J Ophthalmol. Epub ahead of print, 2010.

2. Ho J, et al. Assessment of Artifacts and Reproducibility Across Spectral- and Time-Domain Optical Coherence Tomography. Ophthalmology. 2009;116:1960-70.



Abstract.ControlNumber:171

Abstract.Title:

Treatment Of Uveitis And Outcomes Of Glaucoma Drainage Implant Surgery: A Meta-Analysis

PrimaryAuthor.AuthorBlock:

Meenakshi Chaku, Mingyue Hao, Jae K. Lee, Peter A. Netland. University of Virginia, Charlottesville, VA,
University of Virginia, Charlottesville, VA

Topic.Topic1:Surgery

Abstract.Abstract1:


Introduction: Varying success rates of glaucoma drainage implant (GDI) surgery have been reported in
uveitic glaucoma patients. In this meta-analysis, our purpose was to evaluate the effect of uveitis
treatment on GDI surgical outcomes.
Methods: Two groups were defined prior to analysis based on medical therapy of uveitis. Group 1
included articles with corticosteroid-treated uveitis, with no defined pre- or postoperative control of
uveitis and no immunomodulatory medications. Group 2 included articles with aggressive medically-
treated uveitis, with maintenance of defined pre- and postoperative levels of inflammation and use of
immunomodulatory medications. Variables were analyzed using a one-sided weighted binomial test
(P values < 0.05 significant).
Results: Using PubMed, 16 articles evaluating GDI surgery in uveitic glaucoma patients with
comparable outcome criteria were identified. At Year 1 after GDI surgery, Group 2 (5 articles, 122
eyes) had 95.1% success (95% CI: 91.2-98.9%), which was significantly (P=0.001) higher than 81.6%
success (95% CI: 74.5-88.7%) in Group 1 (11 articles, 114 eyes). Overall success of Group 2 was 86.1%
(95% CI: 79.9-92.2%), which was significantly higher (P=0.014) than 74.3% (95% CI: 66.9-81.6%) in
Group 1.
Discussion: Our meta-analysis demonstrated significantly greater GDI success in Group 2 compared to
Group 1. Potential study limitations include the use of summary data and differences of patients
across studies.
Conclusion: Surgical success was significantly higher in uveitic glaucoma patients treated with more
intensive immunosuppressive therapy before and after GDI surgery. Level of control of uveitis pre-
and postoperatively appears to influence GDI surgery outcomes.
References:
1. Da Mata A, Burk SE, Netland PA, et al. Management of uveitic glaucoma with Ahmed Glaucoma
Valve implantation. Ophthalmology. 1999;106:2168-2172.
2. Vuori ML. Molteno aqueous shunt as a primary surgical intervention for uveitic glaucoma: long-
term results. Acta Ophthalmol. 2010;88:33-36.
3. Ceballos EM, Parrish RK 2nd, Schiffman JC. Outcome of Baerveldt glaucoma drainage implants for
the treatment of uveitic glaucoma. Ophthalmology. 2002;109:2256-2260.

Abstract.ControlNumber:172

Abstract.Title:

Population and High Risk Group Screening for Glaucoma: The Los Angeles Latino Eye Study

PrimaryAuthor.AuthorBlock:

Jonathan Winarko, Brian Francis, Rohit Varma, Cheryl Vigen, Mei-Ying Lai, Betsy Nguyen, Stanley Azen.
Doheny Eye Institute, University of Southern California, Los Angeles, CA, University of Southern
California, Los Angeles, CA, Doheny Eye Institute, University of Southern California, Los Angeles, CA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:
Introduction:
To evaluate glaucoma screening tests in detecting glaucoma in a Latino population and high-risk
subgroups, using preset and optimized cutoff points generated by data analysis.
Methods:
The Los Angeles Latino Eye Study participants (n=6082) underwent Humphrey visual field testing (HVF),
frequency doubling technology perimetry, intraocular pressure, central corneal thickness and
independent assessment of cup to disc ratio (C/D). Three glaucoma groups were evaluated, based on
glaucomatous: 1) optic nerve appearance, 2) visual field, or 3) optic nerve and visual field. Analyses were
also conducted for high-risk subgroups (family history, diabetes, and age >65). Sensitivity and specificity
were calculated for all parameters, and receiver operating curves were calculated for continuous
variables that were independently associated with glaucoma. Classification and Regression Tree (CART)
analysis was used to develop a multivariable algorithm for glaucoma screening.
Results:
Preset cutpoints for screening parameters yielded a poor balance of sensitivity and specificity in the
population and high-risk subgroups. HVF expert reading was the only parameter exhibiting sensitivity
and specificity of 80%. CART showed that overall sensitivity (92%) and specificity (92%) could be
substantially improved by use of multiple screening parameters as well as different cutpoints. The best
single parameter for prediction of glaucoma was C/D using a cutpoint of <0.7 vs. >0.7).
Discussion:
The C/D ratio was the optimal predictor of glaucoma diagnosis, but no parameter by itself produced
sensitivity and specificity of levels sufficient for a practical glaucoma screening program. Nevertheless,
we have shown that a combination of parameters can be used in a simple decision algorithm to
determine glaucoma with high sensitivity and specificity.
Conclusions:
C/D ratio is the optimal parameter for screening for glaucoma, followed by HVF reading. CART showed
that overall sensitivity and specificity could be improved by use of combinations of screening
parameters.
References:
1) Varma R et al. The Los Angeles Latino Eye Study: design, methods, and baseline data. Ophthalmology
2004;111:1121-1131.

Abstract.ControlNumber:173

Abstract.Title:A Comparison Of Visual Function In Patients With Progressive Stages Of Glaucoma
Assessed In The Home And Clinic

PrimaryAuthor.AuthorBlock:

Anjali Bhorade, Monica Perlmutter, Brad Wilson, Sidney Chang, Melike Pekmezci, Michael Kass, Mae
Gordon. Washington University, St. Louis, MO, Washington University, St. Louis, MO, Center for Sight
Maui, Kahului, HI, University of San Francisco, San Francisco, CA

Topic.Topic1:Perimetry and Functional Testing
Abstract.Abstract1:

Introduction:Glaucoma patients state they have visual difficulties despite good performance on vision
tests in the clinic. Little is known regarding differences in visual function at different glaucoma stages
tested in the home vs. clinic.Methods: Consecutive eligible patients with glaucoma staged by the
Glaucoma Staging System1 of the better eye, and normal age-matched controls were enrolled. Certified
examiners measured bilateral ETDRS distance visual acuity, Lighthouse near visual acuity, Pelli-Robson
(PR) contrast sensitivity, and Brightness Acuity Test (BAT) on low and medium settings on participants at
a home and clinic visit. Scores for each vison test were compared between glaucoma stages and
between home and clinic visits using an ANOVA test.Results:138 glaucoma (mean age 72.7 yrs) and 52
normal (mean age 70.9 yrs) participants completed the study. Clinic vision scores significantly decreased
between glaucoma stages for all 5 vision tests and between normal and mild glaucoma for PR and
medium BAT (Table). Vision scores were worse at home than clinic for all groups tested for ETDRS
(p<0.02) and medium BAT (p<0.003) and some groups tested for PR (p<0.0003) and low BAT
(p<0.0002).Discussion:We used a comprehensive assessment of visual function in the home and clinic in
glaucoma patients. We found a progressive decrease in visual function between glaucoma stages on all
vision tests and worse visual function in the home vs. clinic for most vision tests. Conclusions:Visual
function is affected even at early to moderate stages of glaucoma and may be worse in the home than in
the clinic.
References: 1. Mills RP,Budenz DL,et al.Categorizing the stage of glaucoma from pre-diagnosis to end-
stage disease.Am J Ophthalmol 2006;141:24-30.
Abstract.ControlNumber:175

Abstract.Title:Detection of Glaucoma Progression by Population and Individual Derived Variability
Criteria

PrimaryAuthor.AuthorBlock:

Gadi Wollstein, Lindsey S. Folio, Jacek Kotowski, Yun Ling, Richard A. Bilonick, Hiroshi Ishikawa, Larry
Kagemann, Joel S. Schuman. University of Pittsburgh School of Medicine, Pittsburgh, PA

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Purpose: Ocular imaging devices provide quantitative structural assessment that might improve
glaucoma progression detection. The best way to use this information to detect progression remains
unknown. This study examined population-derived versus individual-derived cut-off criteria for
detecting progression.
Methods: 76 healthy, glaucoma suspect and glaucomatous eyes (48 subjects) with at least 4 reliable
visual fields (VF) and good quality scanning laser polarimetry (GDx-ECC) acquired at the same visits were
enrolled. VF progression was defined by the guided progression analysis (GPA) and by the visual field
index (VFI). GDx measurements were analyzed by the standard mode (SM) using a single measurement
from each visit that was compared to the population rate of progression, and the extended mode (EM)
using 3 sets of measurements from each visit that were compared to the individual variability.
Results: Mean baseline VF mean deviation was -1.34 (range: -10.85 to 2.07) dB and mean follow-up
duration was 3.3 (1.6-5.1) years. The proportional rectangular Venn diagrams showed agreement among
VF and GDx SM and EM for the Summary plot (retinal nerve fiber layer (RNFL) thickness slope) and TSNIT
average (RNFL profile change)(Figure). Note that none of the Summary Plot progressors by SM only were
associated with VF progression and the complete dissociation between eyes defined as progressing by
EM and VF for TSNIT Avg.
Discussion: There is poor agreement between VF and GDx progression regardless of the use of
population derived or individual variability criteria.
Conclusion: Further investigation is needed to determine the best method to assess glaucoma
progression.




Abstract.ControlNumber:176

Abstract.Title:Fixed-combination Brimonidine-timolol Vs Latanoprost In Glaucoma And Ocular
Hypertension Patients: A 12-week, Randomized, Comparison Study

PrimaryAuthor.AuthorBlock:

L J. Katz, Steven H. Rauchman, Andrew J. Cottingham, Steven T. Simmons, Julia Williams, Rhett M.
Schiffman, David A. Hollander. Wills Eye Hospital, Philadelphia, PA, North Valley Eye Medical Group,
Mission Hills, CA, South Texas Eye Institute, San Antonio, TX, Glaucoma Consultants of the Capital
Region, Slingerlands, NY, Allergan, Inc., Irvine, CA, Allergan, Inc., Irvine, CA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction:Prostaglandin analogs are commonly used as first-line therapy in glaucoma and ocular
hypertension (OHT). The fixed combination of brimonidine 0.2%-timolol 0.5% reduces intraocular
pressure (IOP) effectively 1 and may be an effective primary therapy in patients intolerant to PGA. This
study was designed to evaluate the IOP-lowering efficacy of fixed brimonidine-timolol compared with
latanoprost in patients with glaucoma or OHT.
Methods:This was a prospective, randomized, multicenter, investigator-masked study. After washout of
previous IOP-lowering medications, patients with IOP ≥ 24 mm Hg were randomized to twice-daily fixed
brimonidine-timolol (n = 73) or once-daily latanoprost (n = 75, dosed in the evening, with a vehicle
control in the morning to maintain masking) for 12 weeks. IOP was measured at 8 am (immediately
before dosing), 10 am, and 3 pm at baseline, week 6, and week 12. The primary efficacy endpoint was
the mean diurnal IOP at week 12. Safety measures included biomicroscopy.
Results:
No significant differences occurred between treatment groups in mean diurnal IOP at baseline
(brimonidine-timolol: 24.7 mm Hg, latanoprost: 25.4 mm Hg, P = .118) or week 12 (brimonidine-timolol:
17.8 mm Hg, latanoprost: 17.9 mm Hg, P = .794). The percentage of patients who achieved a mean
diurnal IOP of < 18 mm Hg at week 12 was 60.3% with brimonidine-timolol and 52.0% with latanoprost
(P = .325). At Week 12, mean biomicroscopic scores of conjunctival hyperemia,eyelid erythema, follicles,
and corneal staining were in the none-to-trace range in both groups.
Discussion:Fixed brimonidine-timolol was as effective as latanoprost in reducing IOP in patients with
glaucoma or OHT. Both treatments provided favorable ocular surface tolerability.
Conclusions:Fixed brimonidine-timolol may be a viable alternative to latanoprost for treatment of
patients with glaucoma or OHT.
References:
1. Sherwood MB, Craven ER, Chou C, et al. Twice-daily 0.2% brimonidine-0.5% timolol fixed-combination
therapy vs monotherapy with timolol or brimonidine in patients with glaucoma or ocular hypertension:
a 12-month randomized trial. Arch Ophthalmol. 2006;124(9):1230-1238.

Abstract.ControlNumber:177

Abstract.Title:Outward Migration of the Anterior and Posterior Lamina Cribrosa Insertions are Core
Components of early Cupping in Non-Human Primate Experimental Glaucoma

PrimaryAuthor.AuthorBlock:

Hongli Yang, Galen Williams, Crawford Downs, Ian A. Sigal, Michael Roberts, Claude Burgoyne. Devers
Eye Institute, Portland, OR, Devers Eye Institute, Portland, OR

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Purpose: To regionally quantify the anterior (inner) and posterior (outer) lamina cribrosa insertions
relative to the scleral canal in both eyes of normal(N) and unilateral early experimental glaucoma (EEG)
monkeys so as to test whether outward migration of the lamina cribrosa from the sclera to the pia is
present in the EEG eyes.
Methods: Perfusion fixed optic nerve heads (ONHs) from both eyes of 12 N and 9 unilateral EEG
monkeys were digitally 3D reconstructed and delineated. Regional and overall values for the following
parameters were calculated for each ONH: anterior laminar insertion position (ALIP), posterior laminar
insertion position (PLIP), laminar insertion length (LIL) and anterior-most subarachnoid space (ASAS)
scleral thickness. Animals were pooled into 4 groups based on treatment and IOP status: N10-N10 (n=6);
N10- N30/45 (n=6); EEG 10-N10 (n=3) and EEG 30/45-N10 (n=6). Treatment effects were assessed within
each monkey and group by ANOVA. Statistically significant EEG monkey inter-eye differences were then
compared to the physiologic inter-eye difference maximum (PID maximum) in the N monkeys.
Results: Outward migration of ALIP and/or PLIP that exceeded the N monkey PID maxima were
regionally present in all 9 EEG eyes. Outward laminar migration achieved partial pialization in 3:9 EEG
eyes and complete pialization in 1:9 EEG eyes. Neither partial nor complete laminar pialization was
present in a single N animal. Outward migration of the PLIP exceeded that of the ALIP in magnitude and
extent within the majority of EEG eyes and the regional maxima of these two parameters did not closely
co-localize in a single EEG eye.
Discussion: Anterior laminar insertion migration likely follows damage to the anterior laminar beam
insertions or their remodeling and may underlie optic disc hemorrhages and excavation. Posterior
laminar insertion migration likely represents a protective remodeling of the laminar, scleral and pial
connective tissues in response to a biomechanically altered environment.
Conclusion: These data are the first to suggest that outward migration of the anterior and posterior
laminar insertions are core components of early cupping in glaucoma.

Abstract.ControlNumber:178

Abstract.Title:Endpoint Committee Increased Validity and Statistical Power in the Ocular Hypertension
Treatment Study (OHTS)

PrimaryAuthor.AuthorBlock:

Mae O. Gordon, Bradley S. Wilson, Patricia A. Morris, Dale K. Heuer, Eve J. Higginbotham, Richard K.
Parrish II. Washington University School of Medicine, St. Louis, MO, Medical College of Wisconsin,
Milwaukee, WI, Howard University, Washington, DC, University of Miami Miller School of Medicine,
Miami, FL

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: The Ocular Hypertension Treatment Study is among the few glaucoma trials with an
Endpoint Committee to determine if the cause of an endpoint was due to POAG. Did the Endpoint
Committee increase accuracy of POAG incidence, treatment differential or statistical power?
Methods: Each reproducible endpoint was reviewed independently by Endpoint Committee members to
determine if the endpoint was “most probably due to POAG” or “most probably not due to POAG”
based on medical/ocular history, visual fields (VF) and stereoscopic optic discs photographs. Optic disc
deterioration also had to be clinically significant. We compare results using all endpoints versus POAG
endpoints. Data are from OHTS phase 1 when participants were managed according to their
randomization assignment.
Results:

Attribution of Cause of Reproducible Endpoints Type of Endpoint

                                                  VF           Optic Disc

                                                  N    Percent N   Percent

POAG                                              59 44        75 56

Probably NOT POAG                                 73 55        5   4
No Change/Not Clinically Significant              1   1        54 40

Total                                             133 100      134 100


16% of the participants developed a reproducible endpoint and 8% developed a clinically significant
POAG endpoint. In the observation and medication groups, 19% and 13% respectively developed a
reproducible endpoint (RR 0.67; 95% CI 0.54-0.84) and 11% and 5% respectively developed a POAG
endpoint, (RR of 0.44; 95% CI 0.31, 0.63). Statistical power to detect a treatment effect for a VF endpoint
was 0.21 and 0.79 for a POAG VF endpoint, 0.95 for a disc endpoint and 0.96 for a POAG disc endpoint.
Discussion: The 16% percent of participants who developed a reproducible “endpoint” includes
endpoints due to non-glaucomatous causes or clinically non-significant endpoints. Only 8% of the
participants developed a clinically significant POAG endpoint. Treatment differential and statistical
power were greater for POAG endpoints than for endpoints overall.
Conclusions: Glaucoma clinical trials might benefit from an Endpoint Committee.

Abstract.ControlNumber:179

Abstract.Title:Reduced Proteolytic Activites And Accumulation Of Proteasomal Aggregates In The
Glaucomatous Trabecular Meshwork.

PrimaryAuthor.AuthorBlock:

Sarah R. Wellik, Anna K. Junk, Sanjoy K. Bhattacharya. Bascom Palmer Eye Institute, Miami, FL

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:

Introduction: The purpose of this study is to investigate proteomic changes in the trabecular meshwork
of patients with primary open angle glaucoma (POAG).
Methods: Trabecular meshwork (TM) specimen from 15 patients with POAG necessitating
trabeculectomy were collected during surgery and flash frozen at -80º C. Control tissue (from 15 age and
gender matched donors) was obtained from the scleral rim of corneal transplant donors not affected
with glaucoma. Proteins were isolated using established procedures and subjected to Western Blot
analysis, mass spectrometry and enzymatic activity assays.
Results: We found elevated calpain-1 and cathepsin D immunoreactivity levels in glaucomatous TM.
Both calpain-1 and cathepsin D kinetic activities were reduced in the glaucomatous TM compared to
controls. Glaucomatous TM revealed notably increased amounts of proteasomal aggregates compared
to controls.
Discussion: Evidence in recent literature supports a role of oxidative protein damage in the etiology of
POAG. Modified calpain proteases may accumulate in the trabecular meshwork of patients with
glaucoma, thereby interfering with TM outflow resistance. In addition, reduced enzymatic activity of
both calpain-1 and the lysosomal protease cathepsin D may be involved in the pathophysiology of
POAG.
Conclusions: These data suggest that reduced proteolytic activities of calpain-1 and cathepsin D in the
TM contribute to the pathophysiology of POAG.
References:
1. Lin Y, Epstein DL, Liton PB. Intralysosomal iron induces lysosomal membrane permeabilization and
cathepsin D-mediated cell death in the trabecular meshwork cells exposed to oxidative stress. Invest
Ophthalmol Vis Sci. 2010. In press.
2. Govindarajan B, Laird J, Salomon RG, Bhattacharya SK. Isolevuglandin-modified proteins, including
elevated levels of inactive calpain-1, accumulate in glaucomatous trabecular meshwork. Biochemistry
2008. 47: 817-825.
3. Junk AK, Goel M, Mundorf T, Rockwood EJ, Bhattacharya SK. Decreased carbohydrate metabolism
enzyme activities in the glaucomatous trabecular meshwork. Molecular Vision 2010. 16:1286-1291.

Abstract.ControlNumber:180

Abstract.Title:Prevalence Of And Risk Factors For Inadequate Glaucoma Eyedrop Bottle Volume

PrimaryAuthor.AuthorBlock:

Mark A. Slabaugh, Raghu Mudumbai, Philip Chen. University of Washington, Seattle, WA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Purpose: One barrier to patient compliance with topical glaucoma treatment is an inadequate amount
of medication available between scheduled prescription refills. We examined the prevalence of and risk
factors for running out of glaucoma eye drops prior to a scheduled refill.
Methods: We surveyed consecutive patients using topical glaucoma therapy in both eyes. Patients were
seen in glaucoma subspecialty clinics from July 1 2010 through October 1 2010. Eligible patients were on
a self-administered drop regimen with no recent changes in their therapy. Patients were asked how
often they ran out of drops early. Other factors examined included insurance status, visual acuity, visual
field data, medical comorbidities and the number of other prescription medications.
Results: 145 patients were eligible and chose to participate during the study period. 15 patients (10.3%)
reported that they “often” (5-7 times per year), “usually” (8-11 times per year) or “always” ran out of
eye drops before they were able to refill their prescriptions.

Factor                          Ran out of drops Did not run out of drops P

Poor Va in better eye (<20/200) 3/15              3/130                    .015

MD better eye                   -8.98 +7.63       -4.47 + 5.79             .013

PSD better eye                  6.84 + 3.86       4.15 + 3.32              .009
Number of glaucoma bottles      1.60 + 0.73       2.15 + 0.83              .015

Number of drops per day         4.73 + 2.89       7.04 + 4.08              .035


Discussion: A notable proportion of patients encounter inadequate bottle volume prior to a scheduled
refill. We found that patients with worse visual acuity, and worse visual field mean deviation and
pattern standard deviation in their better seeing eye were more likely to run out of drops, as were
patients using fewer bottles and administering fewer drops daily. The latter may be due to less practice
with drop administration.
Conclusion: Because of the frequent dosing schedule and the technical difficulty of applying eye drops,
compliance with medical therapy of glaucoma is difficult. Our study indicates that the basic issue of
having adequate medication available is currently a problem for about 10% of patients.

Abstract.ControlNumber:181

Abstract.Title:Long-term Variability Of Ocular Biomechanical Properties Measured By The Ocular
Response Analyzer

PrimaryAuthor.AuthorBlock:

Kaweh Mansouri, Mauro Leite, Linda Zangwill, Felipe Medeiros, Robert N. Weinreb. Hamilton Glaucoma
Center, University of California, San Diego, CA

Topic.Topic1:Other

Abstract.Abstract1:

Long-term variability of ocular biomechanical properties measured by the Ocular Response Analyzer
Introduction: To evaluate the long-term variability of corneal hysteresis (CH) and corneal resistance
factor (CRF) by the Ocular Response Analyzer (ORA) and to investigate the influence of intraocular
pressure (IOP), central corneal thickness (CCT), age and waveform score (WS) on this variability.
Methods: Seventy-six eyes (healthy, suspects, glaucomatous) from 56 patients were recruited at the
University of California, San Diego. CCT, Goldmann applanation tonometry (GAT), CH and CRF were
obtained from all participants in two consecutive visits at least 6 months apart. The concordance
correlation coefficient (CCC) along with the 95% limits of agreement were calculated to evaluate the
inter-visit agreement of GAT, CH, CRF and WS. Univariable regression analysis was performed to
evaluate the influence of age, CCT, GAT fluctuation and WS fluctuation on CH fluctuation and CFR
fluctuation. Subsequently, multivariable models incorporating age, CCT, GAT fluctuation and WS
fluctuation as independent variables and CH and CRF fluctuation as dependent variables were built.
Results: The mean difference between the first and the second measures was 0.15mmHg for CH and
0.34mmHg for CRF. The inter-visit CCC was 0.75 for CH and 0.84 for CRF. Results from univariable
regression models showed no significant influence of age, GAT fluctuation and CCT on CH or CRF
fluctuation was found on CH or CRF fluctuation (P>0.1 for all associations). WS fluctuation had a
significant influence on CH fluctuation (R2=0.10; P<0.001) but not on CRF fluctuation (P=0.657). After
adjusting for age, GAT fluctuation and CCT, WS fluctuation still had a significant effect on CH fluctuation
(P=0.001).
Discussion: The ORA shows good long-term reproducibility in spite of IOP fluctuations.
Conclusions: Fluctuations of the waveform score significantly influenced CH measures and should be
considered when evaluating results from this instrument.

Abstract.ControlNumber:185

Abstract.Title:Glaucoma Management in Patients Undergoing Boston Type I Keratoprosthesis
Implantation

PrimaryAuthor.AuthorBlock:

Jennifer S. Huang, Simon K. Law, JoAnn A. Giaconi, Anne L. Coleman, Joseph Caprioli, Anthony J. Aldave.
Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA

Topic.Topic1:Other

Abstract.Abstract1:

Introduction: The purpose of this study was to review glaucoma management in patients undergoing
Boston type I keratoprosthesis (kpro) implantation with or without concurrent placement of a glaucoma
drainage device (GDD) in a large consecutive case series.
Methods: All kpro procedures by a single surgeon with or without concurrent placement of a GDD
between May 2004 and October 2010 were reviewed.
Results: 102 kpro procedures were performed in 90 eyes of 86 patients. Preoperative prevalence of
glaucoma was 77% (69/90 eyes). Concurrent GDD implantation was performed in 38 of 90 eyes (42%)
while 52 eyes (58%) received no glaucoma surgery at the time of kpro surgery. Mean preoperative
intraocular pressure (IOP) was 22.3 mmHg and 13.7 mmHg in eyes in which a concurrent GDD was and
was not placed, respectively (p<0.0001). Incidence of elevated postoperative IOP (defined as IOP > or
equal to 25 mmHg at any visit) was 18.4% (7 eyes) compared to 13.5% (7 eyes) in patients with and
without concurrent GDD placement, respectively (p=0.57). Of the patients without GDD placement at
the time of kpro implantation, 19.2% (10 eyes) required additional medical therapy for adequate IOP
control compared to 10.5% (4 eyes) in which a GDD was placed at the time of kpro surgery (p=0.38).
While glaucoma surgery was required to manage elevated IOP following kpro implantation in 5.8%
(3/52) of the eyes that did not undergo simultaneous GDD placement, none of the eyes in which a
concurrent GDD was placed required additional glaucoma surgery (p=0.26).
Discussion: Glaucoma is the most common comorbid condition in patients undergoing kpro
implantation. Preoperative IOP is the primary factor that determines whether a GDD is implanted with
the kpro. Although eyes with concurrent GDD implanted with the kpro had higher pre-operative IOP,
they had lower rates of additional glaucoma medications or surgeries required following kpro surgery.
Conclusion: Concurrent GDD implantation should be considered in all cases of elevated IOP undergoing
Boston type I keratoprosthesis implantation.
References:
Aldave AJ, Kamal KM, Vo RC and Yu F. The Boston type 1 Keratoprosthesis: improving outcomes and
expanding indications. Ophthalmology 2009;116:640-51.

Abstract.ControlNumber:186

Abstract.Title:Treatment Outcomes in the Tube Versus Trabeculectomy (TVT) Study After Five Years of
Follow-up

PrimaryAuthor.AuthorBlock:

Steven J. Gedde, Joyce C. Schiffman, William J. Feuer, Leon W. Herndon, James D. Brandt, Donald L.
Budenz. Bascom Palmer Eye Institute, Miami, FL, Duke University, Durham, NC, University of California,
Davis, Sacramento, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction:
Purpose: To report 5-year treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study
Methods:
Design: Multicenter randomized clinical trial
Setting: 17 Clinical Centers
Study Population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract
extraction with intraocular lens implantation and uncontrolled glaucoma on maximum tolerated medical
therapy with intraocular pressure (IOP) ≥ 18 mm Hg and ≤ 40 mm Hg
Interventions: 350-mm2 Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC) 0.4
mg/ml for 4 minutes
Main Outcome Measures: IOP, use of glaucoma medications, failure (IOP > 21 mm Hg or not reduced by
20%, IOP ≤ 5 mm Hg, reoperation for glaucoma, loss of light perception vision)
Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in
the trabeculectomy group. At 5 years, IOP (mean ± SD) was 14.2 ± 6.3 mm Hg in the tube group and 12.8
± 5.8 mm Hg in the trabeculectomy group (p = 0.19). The number of glaucoma medications (mean ± SD)
was 1.4 ± 1.3 in the tube group and 1.2 ± 1.5 in the trabeculectomy group (p = 0.28). The cumulative
probability of failure during the first 5 years of follow-up was 26.1% in the tube group and 46.9% in the
trabeculectomy group (p = 0.002). The rate of reoperation for glaucoma was 9% in the tube group and
19% in the trabeculectomy group (p = 0.025).
Discussion: Tube shunt surgery had a higher success rate compared with trabeculectomy with MMC
during the first 5 years of follow-up in the TVT Study. Both procedures were associated with similar IOP
reduction and use of glaucoma medical therapy at 5 years. Additional glaucoma surgery was needed
more frequently after trabeculectomy with MMC than tube shunt placement.
Conclusions: Tube shunt surgery and trabeculectomy with MMC are good options for managing
glaucoma in patients with prior cataract and/or glaucoma surgery.
References: None

Abstract.ControlNumber:187

Abstract.Title:The Changing Face Of Primary Open Angle Glaucoma In The United States: Demographic
And Geographic Changes From 2010-2050

PrimaryAuthor.AuthorBlock:

Thasarat S. Vajaranant, Shuang Wu, Mina Torres, Rohit Varma. University of Illinois, Chicago, IL, Doheny
Eye Institute, Los Angeles, CA, Doheny Eye Institute, Los Angeles, CA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:


Introduction: Due to an aging and increasingly diverse population, the demographic and geographic
distribution of primary open angle glaucoma (POAG) in the US is changing. An analysis of these changes
will provide data to guide the development of current and future screening and intervention programs.
Methods: For POAG case calculation, the age-, sex-, and race/ethnicity- specific prevalence rates from
selected population-based studies were applied to the US population current estimates and projections
from 2010 to 2050. These data were stratified by state to assess current and future demographic and
geographic variations. Results: In 2010, 2.71 million persons in the US have POAG. The single largest
demographic group of this estimate is non-Hispanic White (NHW) women aged 70 years and older.
Geographically, the highest per-capita case load is in New Mexico,Texas and Florida. In 2050, 7.32
million persons are estimated to have POAG. By 2035, the highest estimates will shift to Hispanic men
aged 70 years and older. Geographically, the highest per-capita burden will be in New Mexico, Texas and
Florida. Discussion: Over the next four decades, there will be a 2.5 fold increase in the number of cases
of POAG in the US. During this period, the highest case load will shift from elderly NHW women to
Hispanic men. The current highest geographic per-capita occurs in states with the largest population of
older NHW women. Over the next four decades, this per-capita case load shifts to states with older
Hispanic men and older NHW women. Conclusions: Despite the high prevalence of POAG in African-
Americans and Hispanics, the largest case load in the US currently is among NHW women. Thus,
currently, the greatest yield from screening programs is likely to be in those states with significant
numbers of older NHW women. Given the demographic changes, over the next few decades, screening
programs should target Hispanic men.
References:
1) Tielsch JM et al. JAMA1991;266(3):369-74.
2) Varma R et al. Ophthalmology 2004;111(8):1439-48.
3) Foster PJ et al. Arch Ophthalmol 2000;118(8):1105-11.

Abstract.ControlNumber:190
Abstract.Title:

Resident Experience Comparing Standard Trabeculectomy with the Ex-PRESS Glaucoma Device for
Treatment of Glaucoma.

PrimaryAuthor.AuthorBlock:

Juner Colina-Luquez, Erika Wandel, Augustine Hong, Thomas Patrianakos. University of Chicago,
Chicago, IL, John H Stroger Jr. Hospital of Cook County, Chicago, IL

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To compare resident results when performing a standard trabeculectomy with
antifibrotics (TrabMMC) with the Ex-PRESS glaucoma shunt (R-50), (Alcon Labs, Inc., Fort Worth, Tx) with
antifibrotics (ExMMC).
Methods: 60 eyes with open angle glaucoma who received either TrabMMC (30 eyes) or an ExMMC (30
eyes) were retrospectively reviewed. Residents were primary surgeons on all cases. Success was defined
as intraocular pressure (IOP) > 5 mmHg and < 20 mmHg. Comparison of pre and post operative IOP,
number of medications between groups, and complications were analyzed.
Results: The mean age was 62 and 57 years in the TrabMMC and ExMMC groups, respectively. Mean
follow-up was 12+/-7 months for TrabMMC and 10+/-6 months for ExMMC. The preoperative IOP was
26+/- 8 mmHg and 29+/- 10 mmHg for the TrabMMC and ExMMC group, respectively (P = 0.04, unpaired
t-test). Postoperative IOP for the TrabMMC was 13, 13, 14 mmHg and for the ExMMC group, 10, 12 and
12 mmHg at 1, 3 and 6 months, respectively (P = 0.25, unpaired t-test). Success at 6 months was 87% for
TrabMMC and 90% for ExMMC. Mean number of ocular hypotensive medications decreased from 4 to 1
in both the TrabMMC and ExMMC group (P<0.0001, paired t-test). There were 5 total cases of
hypotony/choroidals, 2 in the TrabMMC group and 3 in the ExMMC group, and 3 cases of bleb failure, 2
in the TrabMMC group and 1 in the ExMMC group.
Discussion: ExMMC standardizes one of the steps of a trabeculectomy that many residents struggle with
and may lead to better results.
Conclusions: At 6 months, there was no statistically significant difference in success rates, number of
medications pre and post operatively and number of complications between the TrabMMC and ExMMC
group performed by residents.
References:
1. Maris PJ Jr, Ishida K, Netland PA. Comparison of trabeculectomy with Ex-PRESS miniature glaucoma
device implanted under scleral flap. J Glaucoma. 16:14-9, 2007.

Abstract.ControlNumber:192

Abstract.Title:Repeatability of Selective Laser Trabeculoplasty

PrimaryAuthor.AuthorBlock:
Brian A. Francis, Jay Katz, Jason Bacharach, Nils Loewen, Andrew Iwach, Bryan Hong, Ghazal Vakili,
Laurie Dustin. Doheny Eye Institute, Los Angeles, CA, Wills Eye Hospital, Philadelphia, PA, North Bay Eye
Associates, Petaluma, CA, Yale University, New Haven, CT, Glaucoma Associates, San Francisco, CA, Keck
School of Medicine, Los Angeles, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To analyze the results of repeat selective laser trabeculoplasty (SLT).
Methods:
This retrospective, multi-center study included patients from five academic glaucoma specialty
practices. Inclusion criteria were: participants with primary or secondary open angle glaucoma
(excluding uveitic glaucoma) who had undergone SLT 360 degrees (SLT 1) with diminution of response
over time followed by repeat SLT 360 degrees (SLT 2). Six months of follow up were required and at
least 6 months in between SLT 1 and 2. The main outcome measures were IOP reduction at 6 and 12
months, and a comparison of the response between SLT 1 and 2.
Results:
137 patients met the inclusion criteria. If only one eye had repeat treatment, that eye was chosen; if
both eyes qualified, one was chosen at random. The baseline intraocular pressure (IOP) for SLT
1=20.3(5.2) and SLT 2=19.4(5.0) was reduced to 16.4(3.9) and 16.7(4.7) at 1 year, respectively (p<.001).
Medication use was not significantly changed, and was 2.2(1.2) at baseline for SLT 1 and 2.1(1.3) for
SLT 2, and at 1 year was 1.9(1.3) and 2.2(1.2), respectively. A subanalysis of 62 patients with
equivalent baselines showed a baseline IOP=18.7(3.8) for SLT 1 and 18.7(3.5) for SLT 2 reduced to
16.0(4.3) and 15.3(3.8) at 1 year (p<.001).
Discussion:
Repeat SLT laser (360 degree treatment, followed by a loss of effect over time, then a second 360
degree treatment) in this population resulted in a similar IOP lowering to the initial treatment.
Conclusions:
Repeat SLT laser treatment for open angle glaucoma appears to be effective when the first treatment
effect wears off and it is performed a second time.
References:
Hong BK, Winer JC, Martone JF, Wand M, Altman B, Shields B. Repeat Selective Laser Trabeculoplasty. J
Glaucoma 2009;18:180-183.

Abstract.ControlNumber:193

Abstract.Title:

Circadian Variation of Aqueous Humor Dynamics: Effects on Episcleral Venous Pressure and
Uveoscleral Outflow

PrimaryAuthor.AuthorBlock:
Arthur J. Sit, Cherie B. Nau, Mehrdad Malihi, Jay W. McLaren. Mayo Clinic, Rochester, MN

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:

Introduction:
Aqueous humor flow decreases during sleep, while IOP is increased when measured in the physiologic
positions (sitting during day; supine at night). This suggests that outflow facility, uveoscleral flow, or
episcleral venous pressure (EVP) may have circadian rhythms that compensate for the decrease in
aqueous humor flow. Previous studies have not measured enough of these parameters to fully
understand the changes from day to night. In this study, we evaluated circadian variations of all
parameters of aqueous humor dynamics.

Methods:
Twenty-six eyes of 13 healthy subjects (age 47-76; mean 58.8 years) were studied in the mid-diurnal and
mid-nocturnal periods. IOP was measured by pneumatonometry. Aqueous humor flow rate was
determined by fluorophotometry. Outflow facility was measured by Shiøtz tonography. EVP was
measured using a custom-built computerized venomanometer. Uveoscleral outflow rate was calculated
using the modified Goldmann equation. Day and night measurements of each parameter were
compared using paired t-tests.

Results:
At night, aqueous humor flow rate decreases almost 50%, sitting IOP is slightly decreased, and supine
IOP is unchanged. EVP does not change at night, but outflow facility and uveoscleral outflow decrease
significantly.

                                                                                             Uveoscleral
      IOP - Sitting IOP - Supine Aqueous humor Outflow facility                  EVP         outflow
      (mmHg)        (mmHg)       flow (μL/min) (μL/min/mmHg)                     (mmHg)      (% of total
                                                                                             flow)

Day   13.9 ± 3.0      18.2 ± 3.2    2.5 ± 1.0           0.23 ± 0.06              7.4 ± 1.8   29.2 ± 50.6

Night 13.0 ± 1.8      17.8 ± 2.3    1.3 ± 0.6           0.20 ± 0.06              7.4 ± 2.2   0.5 ± 48.0

P     0.031           0.19          <0.001              0.003                    0.95        0.024




Discussion:
Decreased aqueous humor flow at night is compensated by decreased outflow facility and uveoscleral
flow. EVP remains unchanged suggesting active regulation. The lack of uveoscleral outflow at night is
consistent with the concept of a uveolymphatic drainage system that is pressure-insensitive, but
dependent on eye movements.

Conclusions:
Circadian variations in outflow facility, EVP and uveoscleral outflow combine to produce the circadian
IOP pattern.
Abstract.ControlNumber:194

Abstract.Title:IOP Telemetry In Non-human Primates: Initial Characterization Of Continuous IOP At
Multiple Time Scales

PrimaryAuthor.AuthorBlock:

J Crawford Downs, Claude F. Burgoyne, William Seigfried, Juan F. Reynaud. Devers Eye Institute,
Portland, OR

Topic.Topic1:Other

Abstract.Abstract1:

Introduction:
IOP is the most common independent risk factor for development and progression of glaucoma.
However, very little is known about the dynamics of IOP because it is typically measured clinically every
3-12 months using a snapshot device.
Methods:
We have adapted a proven implantable telemetric pressure transducer system to monitor IOP by
integrating the transducer into a orbital wall-mounted baseplate that is connected to the anterior
chamber via a silicone tube. An implanted transmitter sends 500 IOP, ECG and body temperature
measurements per second to an external antenna. Data is acquired with a commercial system equipped
with real-time barometric pressure compensation (ITS, Dexter, MI). We recorded continuous IOP 24
hours/day, 3 days/week for 9 months in two non-human primates, and for one month in a third animal.
Results:
IOP fluctuates as much as 10 mmHg day-to-day and hour-to-hour, and up to 45 mmHg second-to-second
when measured continuously via telemetry in unrestrained, awake non-human primates. Figure 1
shows: 1) typical IOP fluctuations in a resting primate associated with saccadic eye movements; 2) 10-
minute time window averaging for a 24-hour period; 3) 2-hr time window averages for nineteen 24-hr
periods over 19 weeks.
Discussion:
IOP fluctuates tremendously in the non-human primate, which indicates that snapshot IOP
measurements may be inadequate to capture the true dynamic character of IOP in humans. In addition,
IOP fluctuations of this magnitude could be an important yet unknown contributor to IOP-related
glaucomatous damage.
Conclusions:
We have successfully measured IOP continuously using a new implantable IOP telemetry system that
has demonstrated very good accuracy and low drift (<3 mmHg/mo).
Abstract.ControlNumber:195

Abstract.Title:Projected Clinical Outcomes of Glaucoma Screening in African Americans

PrimaryAuthor.AuthorBlock:

Joseph A. Ladapo, Steven M. Kymes, Jonathan A. Ladapo, Veronica C. Nwosu, Louis R. Pasquale. Harvard
Medical School, Boston, MA, Washington University School of Medicine, St Louis, MO, North Carolina
Central University, Durham, NC, Harvard Medical School; Massachusetts Eye and Ear, Boston, MA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction:
Primary open-angle glaucoma affects over 2.2 million Americans, and African Americans face
disproportionately higher rates of glaucoma and glaucoma-related visual impairment. Half of patients
with glaucoma are unaware they have the disease, but no consensus exists on a national screening
policy. Implementing a national screening policy, however, may reduce the incidence of undiagnosed
glaucoma and visual impairment in African Americans and other high-risk populations.
Methods:
Using data from the Eye Diseases Prevalence Research Group, Baltimore Eye Study, and other published
sources, we developed a natural history model to project visual outcomes in African Americans screened
for glaucoma under a national screening policy based on frequency-doubling technology (FDT). We
projected the incidence of glaucoma and glaucoma-related low-vision and blindness, defined as visual
acuity worse than 20/40 or 20/200 in the better-seeing eye, respectively. FDT’s diagnostic characteristics
and the hazard ratio for glaucoma progression in treated patients were informed by meta-analyses, and
the model used a Monte Carlo microsimulation framework.
Results:
Implementation of a national glaucoma screening policy for this year's cohort of African Americans
between the age of 50 and 59 years-old with no prior diagnosis of glaucoma would reduce the lifetime
prevalence of undiagnosed glaucoma from 50% to 22%, and the prevalence of glaucoma-related visual
impairment from 10.8% to 10.1% (a 6.4% decrease). The prevalence of undiagnosed glaucoma would be
lowest at 13% among patients between the age of 50 and 59 years-old and rise to 35% in patients over
the age of 80. The program would cost $78 per screened individual, considering only the cost of FDT and
confirmatory eye exams. The number needed to screen (NNS) to diagnose one person with glaucoma
would be 45. The NNS to prevent one person from developing visual impairment would be 610.
Discussion and Conclusions:
Glaucoma screening for African Americans between 50 and 59 years-old with no history of glaucoma is
potentially clinically effective, though its overall impact on the development of glaucoma-related visual
impairment may be small.

Abstract.ControlNumber:196
Abstract.Title:

Comparison Of The P50, P200 And R50 Ex-PRESS™ Glaucoma Filtration Devices

PrimaryAuthor.AuthorBlock:

Arvind Neelakantan, David G. Godfrey, Ronald L. Fellman. Glaucoma Associates of Texas, Dallas, TX

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: Ex-PRESS™ shunts are commercially available in different sizes and models based upon
differences in design, and size of the internal diameter. Our purpose was to compare surgical outcomes
after implantation of the R50, P50 and P200 models for control of intraocular pressure (IOP) in glaucoma
patients. Methods:A retrospective analysis of 76 Ex-PRESS shunts from Jan 2009 to June 2010 was
conducted. Eyes with less than 3 months of postoperative follow-up (FU) were excluded. Surgical
success was defined as: 5mm Hg ≤ IOP ≤ 18mm Hg with or without medication. Repeat glaucoma
surgery or NLP vision were considered failures. Results:71 eyes of 67 patients met inclusion criteria. 38
of 71 eyes had the procedure combined with cataract surgery. In all three Ex-PRESS models used, the
postoperative IOP and glaucoma medication use was significantly lowered from baseline at final FU
(mean 9.5 ± 4.5 months). The change from baseline IOP was not significantly different in the combined
group when compared to the Ex-PRESS alone group (p=0.89). Surgery was successful in 94.23% P50 eyes
(N=52), 100% P200 eyes (N=11), and 87.5% R50 eyes (N=8) at final FU. The P200 Ex-PRESS shunt model
significantly lowered postoperative IOP when compared to the P50 and R50 models (Fisher t-test, p <
0.05). One eye each in the P50 and P200 groups developed a postoperative choroidal effusion. There
were no eyes with shallow AC’s needing reformation. One eye each in the P50 and P200 groups failed
and needed further glaucoma surgery. Discussion:All three Ex-PRESS shunt models were effective in
lowering IOP in a safe manner, both alone and combined with cataract surgery. The P200 model lowered
IOP more effectively compared to the P50 and R50 models. However the sample size for the P200 and
R50 models were small, and this study has all the inherent problems associated with a retrospective
study.Conclusions:The Ex-PRESS™ glaucoma filtration device is a safe alternative to traditional
trabeculectomy surgery and is as effective in combination with cataract surgery. The P200 model Ex-
PRESS shunt maybe, a reasonable choice in patients with advanced glaucoma or normal tension
glaucoma needing lower postoperative intraocular pressures.

Abstract.ControlNumber:197

Abstract.Title:

Clinical Outcomes of Trabectome® Surgery in Open Angle Glaucoma

PrimaryAuthor.AuthorBlock:
Zachary Vest, David G. Godfrey, Ronald L. Fellman, Arvind Neelakantan. UT Southwestern Medical
Center, Dallas, TX, Glaucoma Associates of Texas, Dallas, TX

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: To examine outcomes of Trabectome surgeries performed at our institution. Our goal was to
compare our initial experience with published outcomes and also to examine if patients presenting with
a higher initial intraocular pressure (IOP) were more likely to require further interventions. Methods: A
retrospective review of Trabectome cases from Sept 2007 to Dec 2009 was conducted allowing for a
minimum follow-up (FU) of 6 months. Second eyes, cases of closed angle glaucoma and eyes with < 6
months FU were excluded, unless they failed earlier. The main outcome studied was IOP. Trabectome
and Phacotrabectome eyes were analyzed as separate groups. A secondary analysis compared eyes with
an initial IOP of <30 mmHg to IOP ≥30 mmHg. Surgical success was defined as IOP ≤ 21mm Hg with or
without medication or 20% decrease in IOP. Repeat glaucoma surgery or NLP vision were considered
failures. Results: 78 of 93 eyes met inclusion criteria. Trabectome™ (n=53) group: Mean preoperative
IOP was 23.2 mmHg on 2.9 medications. Mean IOP at final FU (mean 16 months) was 19.7 mmHg on 2.9
medications. 58.5% eyes (31/53) achieved IOP success. 35.8% eyes failed at a mean of 9.3 months.
Phacotrabectome group (n=25): Mean preoperative IOP was 20.8 mmHg on 2.8 medications. Mean IOP
at final FU (mean 20.4 months) was 15.8 mmHg on 2.4 medications. 80% eyes (20/25) achieved IOP
success. 8% eyes failed at a mean of 7.4 months. Secondary analysis based on initial IOP, showed that
eyes with IOP >30 mmHg (n=10) had a higher failure rate (60% v. 22%) and on average failed earlier (5.5
v. 9.8 months) than those with IOP <30 mm Hg. Discussion: The lower success rate in this study could
possibly be explained by the learning curve innate to a new procedure. 26% of the Trabectome only eyes
and 7% of the Phacotrabectome eyes required further glaucoma surgery. Eyes with an initial IOP of
>30mmHg are unlikely to do well with this procedure alone. Conclusion: Trabectome is a safe small-
incision method for improving IOP control and is more effective in combination with cataract surgery.
This technique offers a reasonable alternative in some patients, sparing conjunctiva for future filtering
surgery.

Abstract.ControlNumber:199

Abstract.Title:

Prediction Of Risk And Rates Of Visual Field Progression In Patients With Established, Treated
Glaucoma

PrimaryAuthor.AuthorBlock:

Gustavo V. De Moraes, Mitra Sehi, David S. Greenfield, Yun S. Chung, Robert Ritch, Jeffrey M. Liebmann.
New York University School of Medicine, New York, NY, Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Palm Beach Gardens, FL, New York Eye and Ear Infirmary, New York,
NY
Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction:To create and test a glaucoma VF progression risk model to predict the global rate of
change (dB/yr) and risk of progression (%).
Methods:Data from 587 treated eyes in which risk factors for VF progression were investigated were
used to create equations predicting global rates of sensitivity change and risk of progression. Multiple
regression coefficients were used to determine the role of baseline (age, CCT, baseline MD, XFS, βPPA)
and intercurrent risk factors (DH, mean and peak IOP, follow-up time) on VF outcomes. A full model (FM,
including all aforementioned variables) and a reduced model (RM, including age, CCT, peak IOP, DH, and
βPPA) were generated and tested in a different prospective glaucoma cohort (62 eyes) followed for ≥4
yrs. Progression endpoints were determined using trend analysis. Progression was defined if ≥2 adjacent
points in the same hemifield progressed (>1dB/yr, p<0.01). We compared the agreement between
observed and predicted global rates of change, final MDs, and risk of progression using both models. We
also compared predicted and observed rates based on the following groups: slow, less than -0.75;
moderate, -0.75 to -1.5; and rapid, more than -1.5 dB/yr.
Results:FM: 37.5% of eyes with a predicted risk >30% reached a progression endpoint, versus 17.8%
with risk ≤15%. The mean (95% CI) difference between predicted and final MDs was -0.95 (-1.44 to -
0.46) dB. The mean difference between predicted and observed rates was -0.23 (-0.33 to -0.13) dB/yr.
RM: 37.5% of eyes with a predicted risk >30% progressed, whereas 12% with risk ≤15% progressed. The
mean difference between predicted and observed final MDs was -0.76 (-1.26 to -0.25) dB. The mean
difference between predicted and global rates of change was -0.18 (-0.28 to -0.07) dB/yr. There was 90%
agreement between predicted and observed values based on slow, moderate, and rapid groups.
Cataract extraction and unreliable VFs were the main causes of disagreement.
Discussion:The prediction model showed moderate efficacy in estimating future VF outcomes in a
separate, treated glaucoma population.
Conclusion:Predictive models may be useful for assessment of risk of progressive VF loss in treated
glaucoma.

Abstract.ControlNumber:200

Abstract.Title:Surgical Complications in the Tube Versus Trabeculectomy (TVT) Study During the First
Five Years of Follow-up

PrimaryAuthor.AuthorBlock:

James D. Brandt, Steven J. Gedde, Joyce C. Schiffman, William J. Feuer, Leon W. Herndon, Donald L.
Budenz. UC Davis, Sacramento, CA, Bascom Palmer Eye Institute, Miami, FL, Duke University, Durham,
NC

Topic.Topic1:Surgery

Abstract.Abstract1:
Introduction:
Purpose: To describe postoperative complications encountered in the Tube Versus Trabeculectomy
(TVT) Study during the first 5 years of follow-up
Methods:
Design: Prospective, multicenter randomized clinical trial
Setting: 17 Clinical Centers
Study Population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract
extraction with intraocular lens implantation and uncontrolled glaucoma on maximum tolerated medical
therapy with intraocular pressure (IOP) ≥ 18 mm Hg and ≤ 40 mm Hg
Interventions: 350-mm2 Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC) 0.4
mg/ml for 4 minutes
Main Outcome Measures: Surgical complications, reoperations for complications, visual acuity, and
cataract progression
Results: Early postoperative complications occurred in 22 (21%) patients in the tube group and 37 (35%)
patients in the trabeculectomy group (p = 0.026). Late postoperative complications developed in 36
(34%) patients in the tube group and 39 (37%) patients in the trabeculectomy group (p = 0.67). The rate
of reoperation for complications was 22% in the tube group and 14% in the trabeculectomy group (p =
0.29). Cataract extraction was performed in 13 (54%) phakic eyes in the tube group and 9 (43%) phakic
eyes in the trabeculectomy group (p = 0.55).
Discussion: The incidence of early postoperative complications was higher following trabeculectomy
with MMC than tube shunt surgery. The rates of late postoperative complications, reoperation for
complications, and cataract extraction were similar with both surgical procedures during the first 5 years
of follow-up.
Conclusions: There were a large number of surgical complications in the TVT Study, but most were
transient and self-limited. Tube shunt surgery and trabeculectomy with MMC have similar safety profiles
in patients with prior cataract and/or glaucoma surgery.
References: None

Abstract.ControlNumber:201

Abstract.Title:The Impact of Glaucoma on Sustained Reading

PrimaryAuthor.AuthorBlock:

Pradeep Y. Ramulu, David S. Friedman, Gary Rubin. Johns Hopkins University, Baltimore, MD, University
College London, London, United Kingdom

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: Nearly one in two individuals with glaucoma describes difficulty reading,[1] though only
those with severe bilateral disease demonstrate slower reading in objective reading tests.[2] One
possible explanation for this discrepancy is that glaucoma produces difficulty when reading over a
prolonged period of time, while prior reading tests only evaluated reading over short durations.
Methods: Glaucoma patients with bilateral field loss and control subjects without visual field loss read a
short passage out loud, and silently read a validated text for 30 minutes. Words per minute (wpm) read
aloud were recorded while the speed of silent reading was inferred from the timing of page turns.
Results: Thirty-eight subjects with glaucoma and 36 control subjects completed the study procedures.
Glaucoma subjects and controls were not significantly different with regards to age, race, gender or
level of education (p>0.1 for all). Glaucoma subjects read slower in both short tests of reading out loud
(150 vs. 164 wpm, p=0.02), and over 30 minutes of silent reading (191 vs. 217 wpm, p=0.1). In
multivariable models, each 1 dB worsening of the better-eye visual field mean deviation was associated
with reading 1.7 wpm slower in short tests of reading out loud (p=0.001), and 3.7 wpm slower over 30
minute periods of silent reading (p=0.002). Over 30 minutes of silent reading, reading speed increased
by 28 wpm/hour in control subjects and decreased by 33 wpm/hour in glaucoma subjects (p=0.07).
Reading speed was more likely to slow down by more than 30 wpm/hour of reading among glaucoma
subjects as compared to controls (OR = 3.5, p=0.02).
Discussion: Glaucoma produces greater effects in prolonged reading than reading over short durations.
Slowing of reading speed in patients with glaucoma may reflect fatigue associated with reading for
prolonged durations.
Conclusions: Patients with glaucoma over a broad spectrum of visual field loss read less rapidly than
those without glaucoma. Identifying these limitations and developing adaptations to help persons with
glaucoma live fuller lives requires further study.
References:
[1] Nelson P, et al. J Glaucoma, 2003;12:139.
[2] Ramulu PY, et al. Arch Ophthal, 2009;127:82.

Abstract.ControlNumber:202

Abstract.Title:Prevalence of Glaucoma in an Urban West African Population: The Tema Eye Survey

PrimaryAuthor.AuthorBlock:

Donald L. Budenz, Joyce Schiffman, Jagadeesh Bandi. Univesity of Miami Miller School of Medicine,
Miami, FL

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: The purpose of the current study was to determine the prevalence of glaucoma in an
urban West Africa population.
Methods: A random cluster sampling of adults age 40 and over was conducted in the city of Tema,
Ghana, West Africa. Subjects underwent a field examination consisting of visual acuity, frequency
doubling perimetry, Tonopen intraocular pressure, and optic disc photography. Subjects who failed
any of these tests were referred for compete examination by s study ophthalmologist with
gonioscopy, standard white-on-white perimetry, and stereoscopic optic disc photographs. Masked
readers assessed all optic disc photographs and visual fields. The definition of glaucoma by Foster and
associates1 was applied and the type of glaucoma was determined by study investigators who
examined subjects.
Results: 6806 eligible subjects were identified of which 5603 (82.3%) participated in the study. The
field examination identified 1869 (33.3%) subjects who failed the screening examinations. Of these,
1538 came back to the clinic for complete examination for a participation rate at this stage of 82.2%.
The number of category 1 glaucoma (definite glaucomatous optic disc and visual field abnormality)
was 353 (6.3%), category 2 glaucoma (advanced optic disc damage with unproven visual field loss) was
39 (0.7%), and category 3 glaucoma (IOP ≥ 35 mmHg and VA < 20/400 with optic disc not seen and
visual field test impossible OR visual acuity < 20/400 and evidence of previous glaucoma filtering
surgery or medical record confirmation of glaucomatous visual morbidity) was 8 (0.14%). Combining
all 3 categories, the prevalence of glaucoma was 400 out of 5603 (7.1%). Primary open angle glaucoma
was identified in 96.8% of subjects with glaucoma and chronic narrow angle glaucoma accounted for
the remaining 3.2%.
Conclusions: Glaucoma is extremely prevalent in urban West Africa. Strategies to identify affected
patients and effectively manage the disease are needed.
References: 1 Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and classification of
glaucoma in prevalence surveys. Br J Ophthalmol 2002;86:238-242.

Abstract.ControlNumber:203

Abstract.Title:Outcomes of Glaucoma Reoperations in the Tube Versus Trabeculectomy (TVT) Study

PrimaryAuthor.AuthorBlock:

Hady Saheb, Steven Gedde, Joyce Schiffman, William Feuer. Bascom Palmer Eye Institute, Miami, FL

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction:
Purpose: To describe the outcomes of patients who underwent reoperations for glaucoma in the Tube
Versus Trabeculectomy (TVT) Study.
Methods:
The TVT Study enrolled patients with medically uncontrolled glaucoma who had previous cataract
and/or glaucoma surgery and randomized them to surgical treatment with a tube shunt or
trabeculectomy. Data were analyzed from patients who failed their assigned treatment and
subsequently had additional glaucoma surgery. Outcome measures included intraocular pressure (IOP),
visual acuity (VA), use of glaucoma medications, failure (IOP > 21 mm Hg or not reduced by 20%, IOP ≤ 5
mm Hg, reoperation for glaucoma, loss of light perception vision), and surgical complications.
Results:
Additional glaucoma surgery was performed during the first 5 years of follow-up in 26% of patients in
the TVT Study, including 9% in the tube group and 19% in the trabeculectomy group (p = 0.025). In the
tube group, 4 (50%) patients underwent implantation of a second tube shunt as a glaucoma reoperation
and 4 (50%) patients had a cyclodestructive procedure. In the trabeculectomy group, a tube shunt was
placed in 17 (94%) patients requiring a reoperation. After 2 years, IOP (mean ± SD) was 15.0 ± 5.5 mm
Hg in the tube group and 15.5 ± 8.3 mm Hg in the trabeculectomy group (p = 0.87). The number of
glaucoma medications (mean ± SD) was 1.1 ± 1.4 in the tube group and 1.5 ± 1.5 in the trabeculectomy
group (p = 0.66). The cumulative probability of failure during the first 2 years of follow-up was 29% in
the tube group and 9% in the trabeculectomy group (p = 0.45). Surgical complications developed in 2
(25%) patients in the tube group and 8 (44%) patients in the trabeculectomy group (p = 0.42).
Discussion:
Patients in the tube group underwent placement of a second tube shunt or a cyclodestructive procedure
with similar frequency, while most patients in the trabeculectomy group had tube shunt surgery as a
glaucoma reoperation. Similar surgical outcomes were observed between the tube and trabeculectomy
groups following additional glaucoma surgery.
Conclusions:
Successful control of IOP was usually achieved in patients who had glaucoma reoperations in the TVT
Study.

Abstract.ControlNumber:204

Abstract.Title:

Delayed-onset Symptomatic Hyphema Following Trabectome Surgery: A Single Center Case Series

PrimaryAuthor.AuthorBlock:

Yachna Ahuja, Mehrdad Malihi, Arthur J. Sit. Mayo Clinic, Rochester, MN

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: Trabectome surgery reduces IOP by ablating a segment of trabecular meshwork. While
blood reflux is extremely common intraoperatively, delayed-onset hyphema in the absence of further
ocular surgeries or trauma has not previously been reported. In this study, we describe a series of
patients who experienced delayed-onset symptomatic hyphema after Trabectome surgery for open-
angle glaucoma.
Methods: : Cases of delayed-onset, symptomatic hyphema were identified from patients who had
Trabectome surgery at Mayo Clinic by a single surgeon (AJS) between 2006 and 2010. The diagnosis of
hyphema was made on the basis of slitlamp examination and gonioscopy.
Results: Out of 250 cases of Trabectome surgery, there were 11 cases (1 male and 10 females) of
delayed-onset symptomatic hyphema (4.4%). Average age was 74.8 years (range 66-82 years). Time of
onset of hyphema ranged from 2 to 31 months after surgery. The most common symptom at
presentation was transient blurry vision upon awakening. The most common patient characteristic was
maintaining a sleep position toward the side that had undergone Trabectome surgery. Most cases of
hyphema resolved within 1-2 weeks with the exception of one patient who required trabeculectomy
due to an irreversible IOP spike.
Discussion: Although Trabectome patients have an open blood-aqueous barrier, the proportion of
patients developing late-onset symptomatic hyphemas is small. The likely mechanism is ocular
compression from a sleeping position on the surgical side, followed by sudden decompression and blood
reflux when the pillow was removed. Asymptomatic hyphemas may also occur but were not identified in
this series.
Conclusions: Delayed-onset hyphema after Trabectome surgery can occur and patients should be aware
of the symptoms. Patients should avoid sleeping towards the side of surgery, particularly if they
experience hyphema symptoms upon awakening.

Abstract.ControlNumber:205

Abstract.Title:Hydrodynamic and Morphological Correlations to Increased Aqueous Outflow Facility
after Y27632 Treatment in Bovine, Monkey and Human Eyes

PrimaryAuthor.AuthorBlock:

Haiyan Gong, Chen-Yuan C. Yang, Zhaozeng Lu, Ye Liu. Boston University School of Medicine, Boston,
MA, Huashan Hospital of Fudan University, Shanghai, China

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:

Introduction:
We investigated anatomical correlations of increased outflow facility (C) after Y27632 treatment in
bovine, monkey and human eyes.
Methods:
Experimental eyes (7 bovine, 4 monkey, 4 human) were perfused with GPBS+50 µM Y27632 for 30 min
and an additional 5 human eyes for 3 hours. Control eyes (5 bovine, 4 monkey, 4 human for 30 min
each, 5 human for 3 hr) were each perfused with GPBS. All eyes were perfused with fluorescent
microspheres to label outflow patterns before perfusion-fixation. Confocal images were taken along the
inner wall (IW) of Schlemm’s canal (SC). Total length (TL) and tracer-decorated length (L) of the IW were
measured, and the average percent effective filtration length (PEFL=L/TL) was calculated. Thickness of
the trabecular meshwork (TM) with high and low flow was measured and analyzed in human eyes.
Sections with SC were examined by light and electron microscopy. The TL of the IW and the length
exhibiting IW and juxtacanalicular tissue (JCT) separation (SL) were measured. The average percent
separation length (PLS= SL/TL) was calculated.
Results:
After 30 min Y27632 perfusion, C increased 58% (p=0.03) in bovine, 115% (p=0.03) in monkey, but
remained unchanged in human eyes (p=0.98). After 3 hrs Y27632 perfusion of human eyes, C increased
significantly (p=0.039) compared to controls. After 30 min Y27632 perfusion, PEFL was significantly
increased in bovine (p=0.002) and monkey (p<0.001), but unchanged in human (p=0.41) compared to
controls. After 3 hrs Y27632 perfusion in human eyes, PEFL was 1.4-fold larger compared to controls
(p<0.05). PSL was significantly increased compared to controls in bovine (p<0.001) and monkey
(p=0.001). No discernable separation between the IW and JCT were found in all human eyes, but the
thickness of TM was significantly larger in high flow regions over low flow regions (p<0.05).
Discussion:
After Y27632 treatment, different morphological changes in the TM were found in bovine, monkey and
human eyes. These different changes resulted in a similar increase in PEFL, which in turn was positively
correlated with an increase in C.
Conclusions:
PEFL may be the best anatomical parameter to correlate with increased C in three species.
References:

Abstract.ControlNumber:206

Abstract.Title:Risk Factors Associated With Aqueous Tube Shunt Extrusion: A Retrospective Case-control
Study

PrimaryAuthor.AuthorBlock:

Kundandeep S. Nagi, Robert Feldman, Nick Bell, Alice Chuang, Laura Baker, Stephen Huddleston, David
Lee, Michael Koval, Ricardo Cumba. University of Texas Health Sciences Center at Houston, Houston, TX,
University of Texas Health Science Center at Houston, Houston, TX, University of Texas Medical School at
Houston, Houston, TX, University of Texas Medical School at Houston, Houston, TX

Topic.Topic1:Surgery

Abstract.Abstract1:

PURPOSE: To investigate the risk factors that may lead to aqueous tube shunt extrusion in glaucoma
patients.
METHODS: A retrospective 1:2 matched case-control study utilizing medical records from patients that
underwent implantation of glaucoma drainage devices with patch grafts at the Robert Cizik Eye Clinic,
UTHealth from 1995 to 2005. Eyes with tube erosion were identified as cases and each matched with
two controls that underwent tube shunt implantation within 6 months of the case. Demographic,
systemic and ocular histories, as well as implantation parameters were recorded. Statistical analysis,
including two sample t-test and Fisher-Exact test, was used to compare each risk factor and a stepwise
conditional logistic regression was used to identify risk factors associated with erosion.
RESULTS: Eighteen cases and 36 controls were included in this study. Among them, 33% were male, 52%
were black, with a mean age of 58 (±20) years. There were no statistically significant differences in race,
age, hypertension, diabetes, number of glaucoma lowering medications, and surgery parameters. The
risk of erosion was increased if an eye had neovascular (NVG) glaucoma (28% vs 6%, p=0.034), more
than 3 ocular surgeries prior to implantation (56% vs 22%, p=0.030), and previous tube implantation
(second shunts) (22% vs 3%, p=0.037). Conditional logistic regression confirmed two risk factors: NVG
and previous tube implantation.
DISCUSSION: This study has identified 2 risk factors: NVG and prior tube implantation. This may be
related to poor tissue distensibility and wound healing. Overall, previous ocular surgery (greater than 3)
also correlated with increased risk of erosion, though although the sample size is too small to analyze
the specific surgeries involved.
CONCLUSION: Eyes with NVG and a history of previous tube implantation were associated with
increased risk of tube extrusion.

Abstract.ControlNumber:207

Abstract.Title:

Day And Night Differences In Aqueous Humor Dynamics In Patients With Ocular Hypertension (OHT)
Treated With Latanoprost, Dorzolamide And Timolol

PrimaryAuthor.AuthorBlock:

Carol B. Toris, Shan Fan, Vikas Gulati, Carl B. Camras. University of Nebraska Medical Center, Omaha, NE

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:

Introduction Little is known about the 24 hour variations in aqueous humor dynamics in OHT patients.
This study investigates the 24 hour IOP and aqueous humor dynamics of 30 OHT patients taking three
common glaucoma drugs.
Methods This double-masked study evaluates the day and night differences in IOP and aqueous humor
dynamics at baseline (washout) and following two weeks of treatment with latanoprost, timolol and
dorzolamide in a randomized crossover design with washout between drugs. Day and night assessments
were made of IOP (mmHg) by pneumatonometry, aqueous flow (Fa, µL/min) by fluorophotometry,
outflow facility by tonography (Cton, µL/min/mmHg), and CCT (µm) by pachymetry. Uveoscleral outflow
(Fu) was calculated. Comparisons among the drugs were made by repeated measured ANOVAs and
paired t-tests.
Results At baseline, significant nighttime changes were reductions in seated IOP, Fa and Fu and
increases in CCT and habitual IOP (*P<0.05). Changes after drug treatment are summarized below.

             % Change from Daytime Baseline % Change from Nighttime Baseline

             Latanoprost Timolol Dorzolamide Latanoprost Timolol Dorzolamide

Seated IOP -18*           -17*    -14*          -12*          -1      -3

Habitual IOP -18*         -17*    -14*          -9*           0       -4

Fa           -4           -25*    -16*          -4            -1      -1
Cton         -4           -22     -13           5            -15      -10

Fu           309*         219     165           97           113      51

CCT          -1           0       -1            0            0        0


Discussion Physiological changes in aqueous humor dynamics occur at night that affect the efficacy of
commonly used glaucoma drugs. Future studies are needed to understand the mediating pathways for
nocturnal changes and utilize these to develop more efficient round-the-clock IOP lowering and control
of glaucoma.
Conclusions The daytime IOP effects of latanoprost are mediated by stimulation of uveoscleral outflow
and for timolol and dorzolamide by aqueous humor suppression. Nighttime physiological changes in
uveoscleral outflow limit the nighttime IOP lowering efficacy of latanoprost. Aqueous humor
suppression is an ineffective means of lowering IOP at nighttime.

Abstract.ControlNumber:209

Abstract.Title:

“ECP-Plus” to Treat Refractory Glaucoma

PrimaryAuthor.AuthorBlock:

James C. Tan, Ghazal Vakili, Robert Noecker, Brian Francis. University of Southern California, Los
Angeles, CA, University of Pittsburgh, Los Angeles, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

PURPOSE: To report clinical outcomes following endoscopic cyclophotocoagulation (ECP) of the
posterior ciliary processes and pars plana ("ECP-plus") via a pars plana (PP) approach for refractory
glaucoma.
METHODS: Retrospective analysis of clinical data from subjects followed for at least 3 months (m) after
360 degree ECP-plus following PP vitrectomy. Subjects had uncontrolled intraocular pressure (IOP)
despite prior glaucoma surgery and maximally tolerated medical therapy. The primary outcome was IOP,
and secondary outcomes were complications.
RESULTS: 53 subjects’ data were analyzed. 32.1% (17/54) had primary open angle glaucoma (POAG),
26.4% (14/54) had chronic angle closure glaucoma, and the rest (41.5%) had secondary OAG. 28/53 of
subjects had 12m, and 10/53 had 24m of follow up respectively. Mean preoperative IOP was
27.9±7.5mmHg (mean±SD). Postoperative IOP at 1m (11.5±8.8), 3m (8.9±5.7), 6m (9.6±4.6), 12m
(10.7±5.2), 18m (8.1±5.1) and 24m (11.1±6.5) was significantly lower than before laser (all p21mmHg;
IOP reduction<20%; hypotony (IOP≤5mmHg) on 2 consecutive follow ups after 1m; further glaucoma
surgery; or loss of light perception) was 85% at 1m, 78% at 12m, and 78% at 24m. Mean number of
medications fell from 3.4±1.2 pre-laser to 1.1±1.1 at 1m (p<0.0001), 0.7±1.2 at 12m (p<0.0001), and
0.6±1.3 (p=0.0005) at 24m postoperatively. In the initial postoperative period (<3m), 2/53 had
hypotony, with both having choroidal detachments; 2/53 had uveitis with fibrin. After 3m, 4/53 had
hypotony, with 3/4 having choroidals. 3/53 needed further related surgery, 2/3 of whom had hypotony.
1/53 had a failed corneal graft. All initial uveitis had resolved. No subjects suffered retinal detachment
or endophthalmitis.
DISCUSSION: IOP was significantly lowered by a mean of at least 58% following ECP-plus. IOP reduction
was relatively sustained over the follow up period and fewer glaucoma medications were needed. 7.5%
had hypotony beyond 3m postoperatively.
CONCLUSION: ECP-plus is effective in lowering IOP in refractory cases of glaucoma, patients require
fewer medications postoperatively, and the treatment is relatively well tolerated.
REFERENCES: None

Abstract.ControlNumber:210

Abstract.Title:

Reproductive Factors And Primary Open-Angle Glaucoma In The Nurses’ Health Study

PrimaryAuthor.AuthorBlock:

Louis R. Pasquale, Jae Hee Kang. Harvard Medical School, Boston, MA, Brigham and Women's Hospital,
Boston, MA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: Estrogen receptors are expressed on retinal ganglion cells and estrogen is neuroprotective
in animal models of glaucoma. During pregnancy when circulating estrogen levels are high, women
experience decreased IOP.
Purpose: We explored the relation between age at menarche, parity and oral contraceptive (OC) use
and POAG.
Methods: We followed 79,441 women in the Nurses’ Health Study prospectively from 1980 to 2006 and
identified 812 cases of incident POAG. Eligible participants were ≥ 40 years old, free of POAG at baseline,
had information on reproductive history and reported receiving eye examinations during follow-
up. Relevant exposure data and POAG risk factors were updated using biennial questionnaires. We used
proportional hazards models to calculate multivariable rate ratios (MVRR) of POAG and 95% confidence
intervals [CI].
Results: In multivariable analysis, there was no trend between age at menarche (p for trend = 0.46) or
reproductive duration (p for trend = 0.08) and POAG. While ever using OCs was not associated POAG
risk, longer duration of OC was associated with a modest 25% increased risk of POAG (95% CI, 1.02-1.53;
p for trend=0.05). There was a suggestion that this association was stronger among younger women
(<65 years; MVRR,1.44; 95% CI, 1.07, 1.93; p=0.02). Parity was not associated with POAG risk.
Discussion: Just as OC use may predispose to thrombotic stroke and retina venous occlusive disease,
disruption of the physiological fluctuation of sex steroids may predispose to glaucomatous optic
neuropathy.
Conclusion: Reproductive duration and parity were not related to POAG risk but five or more years of
OC use was associated with a modestly increased risk of POAG.
References:
Zhou X, et al. Retinal ganglion cell protection by 17-beta-estradiol in a mouse model of inherited
glaucoma. Dev Neurobiol. 2007;67(5):603-616.
Russo R, et al. 17Beta-estradiol prevents retinal ganglion cell loss induced by acute rise of intraocular
pressure in rat. Prog Brain Res. 2008;173:583-590.
Green K, et al. Aqueous humor flow rate and intraocular pressure during and after pregnancy.
Ophthalmic Res. 1998;20(6):353-357.

Abstract.ControlNumber:213

Abstract.Title:

Effects of Benzalkonium Chloride-, Polyquad™-, and sofZia™-preserved Topical Glaucoma Medications
on Human Trabecular Meshwork Cells

PrimaryAuthor.AuthorBlock:

Malik Y. Kahook, David A. Ammar. University of Colorado, Aurora, CO

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:

Introduction:
We investigated the potential cytotoxicity in cultured human trabecular meshwork (TM) cells of various
topical ophthalmic glaucoma formulations containing different preservatives.
Methods:
We tested 0.004% travoprost preserved with either 0.015% benzalkonium chloride (BAK), sofZia™, or
polyquad™(PQ); and timolol with 0.020% BAK or preservative free. Also tested was a range of BAK
concentrations (0.001 - 0.020%). TM cells were treated for 25 minutes at 37°C and 5% CO2 with 100 µL
of solutions diluted 1:10 to mimic the reduced penetration of topical preparations to the anterior
chamber. Uptake of the fluorescent vital dye (calcien-AM) was used to determine the percentage of live
cells. For test solutions diluted 1:10, BAK demonstrated a dose-dependent reduction in cell viability.
Results:
Diluted 1:10, travoprost +BAK had statistically fewer live cells (83%) than both travoprost + sofZia (100%)
and travoprost + PQ (91%; p < 0.05). Similarly, compared to preservative-free timolol, timolol + BAK
showed a significant decrease in viability (61% vs. 50%).
Discussion:
These results demonstrate that the substitution or removal of the preservative BAK from topical
ophthalmic drugs results in greater viability of TM cells, the cells involved in maintaining the
conventional outflow pathway in vivo.
Conclusions:
Further studies are needed to investigate the penetration into the anterior chamber of this preservative
commonly used in topical glaucoma treatments.

Abstract.ControlNumber:215

Abstract.Title:

Resveratrol: Potential Clinical Applications in Glaucoma Surgery

PrimaryAuthor.AuthorBlock:

Molly M. Walsh, Pedro Gonzalez, Kelly Searle. Duke University, Durham, NC

Topic.Topic1:Surgery

Abstract.Abstract1:

Resveratrol: Potential Clinical Applications in Glaucoma Surgery
Purpose: Many trabeculectomy procedures ultimately fail due to fibroblast proliferation which can
ensue postoperatively. Recent studies in other surgical subspecialties have shown potential for the
adjunctive use of resveratrol to inhibit scarring after various surgical interventions. Our hypothesis is
that the anti-scarring properties of resveratrol may potentially be used to decrease scarring after
trabeculectomy.
Methods: 14 New Zealand white rabbits underwent trabeculectomy on their right eye. 7 of the rabbits
were placed on resveratrol (5 mg/kg) in their drinking water. This treatment was initiated one week
prior to the surgery and was continued daily until one month after the trabeculectomy. IOPs (intraocular
pressures) were recorded weekly using a Tonopen device. Immunohistochemistry was then used to
determine differences in collagen and fibroblast expression in both eyes.
Results: The average IOP difference in the control group at 1 month after trabeculectomy was an
increase of 2.14 mmHg. However, the average difference observed in the resveratrol group was a
decrease of 1.71 mmHg.
Discussion: Therefore, the difference between the treated and untreated groups was 3.85 mmHg which
was statistically significant (p value of 0.014).
Conclusions: This study suggests that there may be a potential beneficial role for adjunctive therapy with
resveratrol for patients undergoing trabeculectomy.
References:
Bedirli A, et al. Effects of Nuclear Factor-kappaB inhibitors on colonic anastomotic healing in rats. J Surg
Res. 2010, 1-6.
Sogutlu G, etal. The effect of resveratrol on surgery-induced peritoneal adhesions in an experimental
model. Cell Biochem. Funct. 2007; 25 (2): 217-220.
Van Ginkel PR, et al. Resveratrol inhibits uveal melanoma tumor growth via early mitochondrial
dysfunction. IOVS 2008; 49 (4): 1299-1306.

Abstract.ControlNumber:216

Abstract.Title:Reproducibility of Retinal Nerve Fiber Layer Thickness Measurements Using Spectral
Domain Optical Coherence Tomography

PrimaryAuthor.AuthorBlock:

Teresa C. Chen, Huijuan Wu, Johannes De Boer. Massachusetts Eye and Ear Infirmary, Boston, MA, VU
University, Amsterdam, Netherlands

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Introduction:
To evaluate the reproducibility of retinal nerve fiber layer (RNFL) thickness measurements obtained by
spectral domain optical coherence tomography (SDOCT) in normal and glaucoma subjects.
Methods:
Participants were recruited from a university-based clinic. Peri-papillary RNFL thickness measurements
were repeated three times during the same visit (Spectralis, Heidelberg Engineering, Heidelberg,
Germany). One eye of each patient was randomly selected for statistical analysis. Reproducibility was
evaluated using within-subject standard deviation (Sw), coefficient of variation (CV), and intraclass
correlation coefficient (ICC). Spearman's rank correlation coefficient analyses were used to assess the
correlation of the standard deviation of the 3 measurements for each patient with the RNFL thickness
value.
Results:
Forty-five normal subjects and 33 glaucoma patients were included in the study. The CVs ranged from
1.45% [overall global (G)] to 2.59% [temporal quadrant (T)] in normal eyes and 1.74% (G) to 3.22% (T) in
glaucomatous eyes. ICCs ranged from 0.977 (T) to 0.990 (G and inferior-nasal sector) in normal eyes and
0.983 (T) to 0.997 (inferior quadrant) in glaucomatous eyes. Sw were from 1.34µm (G) to 2.39µm
(superior-temporal and inferior-temporal sectors) in normal eyes and 1.14µm (G) to 2.25µm (superior-
nasal sector) in glaucomatous eyes. There were no significant correlations between RNFL thickness
values and measurement variability for each patient.
Discussion:
To our knowledge, this is the first study which evaluates the reproducibility of RNFL thickness
measurements in normal and glaucoma patients using an SDOCT machine with tracker.
Conclusions:
SDOCT shows excellent reproducibility for measuring peri-papillary RNFL thickness values in both
healthy and glaucoma subjects.
References:
Wu H, de Boer JF, Chen TC. Reproducibility of RNFL Thickness Measurements Using SDOCT. J Glaucoma
2010, in press.

Abstract.ControlNumber:217

Abstract.Title:Second Generation Stents in Mild-Moderate Open Angle Glaucoma: Design Review and
Initial Clinical Data from Prospective, Randomized Study

PrimaryAuthor.AuthorBlock:

Jason Bacharach. North Bay Eye Associates, Inc., Petaluma, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: Our purpose is to review product design and initial clinical data following implantation of
second generation stents during cataract surgery vs. cataract surgery alone in mild to moderate open-
angle glaucoma.

Methods: A second generation trabecular bypass stent is under clinical investigation in a prospective,
randomized US IDE study. This single-piece heparin-coated titanium stent is inserted in Schlemm’s canal
via ab interno implantation through a temporal corneal incision. Multiple outlet lateral lumens are
designed to provide an exit route for aqueous from the anterior chamber. Preclinical in vitro work has
shown increased outflow facility with this device.[1]The initial study phase involved 44 subjects
randomized to implantation of two stents during cataract surgery (treatment) or cataract surgery only
(control). Postoperative examinations were at 1 day, 1 week and 1, 3, 6, 12, 18 and 24 months. Analyses
of safety included adverse events and complications. One year IOP ≤ 18 mmHg without medication was
the primary efficacy endpoint.

Results: Seventy-seven percent (20/26) of treatment eyes and 24% (4/17) of control eyes met the
primary efficacy endpoint. Postoperative adverse events > 10% were elevated IOP at any visit (11%
treatment vs. 47% control), conjunctivitis (7% treatment vs. 12% control), BCVA loss > 1 line (0%
treatment vs. 12% control) and eye pain (0% treatment vs. 12% control).

Discussion: In this series, overall safety was comparable in both groups. IOP was managed to ≤ 18 mmHg
without medication at 1 year in a higher proportion of stent subjects, suggesting an incremental benefit
of stent implantation vs. cataract surgery alone.

Conclusions: These data form the basis for continued investigation in mild to moderate open-angle
glaucoma requiring cataract surgery.

References: [1]. Bahler CK, et al. Second generation trabecular meshwork bypass stent increases
outflowfFacility in cultured human anterior segments. ARVO poster, Ft. Lauderdale, FL, May 2010.
Abstract.ControlNumber:218

Abstract.Title:Clinical Characteristics Of Glaucoma Patients With High Myopia

PrimaryAuthor.AuthorBlock:

Simon K. Law, Maha Sami, JoAnn Giaconi, Anne L. Coleman, Kouros Nouri-Mahdavi, Joseph Caprioli. Jules
Stein Eye Institute, Los Angeles, CA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction:
Detection of glaucoma in eyes with high myopia is often difficult because eyes with high myopia may
have glaucoma-like optic disc appearance and abnormal visual field. This study is to evaluate the clinical
characteristics of glaucoma patients with high myopia.
Methods:
Medical records of patients seen in our Glaucoma Clinic from 1999 to 2009 were reviewed. Patients who
were <55 years of age with spherical equivalent <-5 diopters were enrolled. The diagnosis of glaucoma
was defined by optic disc or visual field characteristics typical for glaucoma. Clinical characteristics were
compared between eyes with glaucoma and eyes without glaucoma. Logistic modeling accounted for
enrollment of two eyes of subjects.
Results:
Medical records of >2000 patients were reviewed. 162 patients (291 eyes) were enrolled including 85
eyes with primary open angle glaucoma and 206 eyes without glaucoma. Refractive error did not differ
significantly between the two groups. In univariate analysis, myopic eyes with glaucoma were
significantly different from myopic eyes without glaucoma in terms of age (44.8+/-6.7 vs. 40.7+/-10.1
years, respectively, p=0.006), central corneal thickness (553+/-35 vs. 573+/-37 microns, p=0.001),
cup/disc ratio (0.68+/-0.23 vs. 0.47+/-0.20, p=0.019), average retinal nerve fiber layer (RNFL) thickness
measured by optical coherent tomography (68.25+/-18.32 vs. 91.64+/-15.43, p=0.011), superior RNFL
thickness (81.28+/-26.37 vs. 108.69+/-24.22, p=0.016), inferior RNFL thickness (77.76+/-27.46 vs.
109.55+/-23.17, p=0.019). There is a strong trend of the mean deviation of visual field of myopic eyes
with glaucoma to be less than the non-glaucoma myopic eyes (-6.65+/-8.32 vs. -2.35+/-4.07, p=0.054).
Age and inferior RNFL remained statistically significant in multivariate analysis.
Conclusions:
Eyes with high myopia and glaucoma are significantly older with thinner central corneas, greater
cup/disc ratio, and thinner RNFL measurement than in non-glaucoma eyes with similar degrees of
myopia.
References:
Xu L, et al. High Myopia and Glaucoma Susceptibility. The Beijing Eye Study. Ophthalmology
2007;114:216-220.

Abstract.ControlNumber:219
Abstract.Title:

24-hour Intraocular Pressure (IOP) Reduction of Taprenepag Isopropyl (PF-04217329) Alone and In
Combination With Latanoprost

PrimaryAuthor.AuthorBlock:

Susan Raber, Min Zhang, Charles S. Tressler, Ronald A. Schachar. Pfizer Inc, San Diego, CA, Pfizer Inc,
New York, NY

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Purpose: To characterize the 24-hour IOP reduction of the EP2 agonist taprenepag isopropyl (TAP) alone
and in an unfixed combination with latanoprost (LAT).
Methods: Randomized, single-masked, crossover study of 14 days of TAP 0.01% alone and with LAT
0.005% at 8AM in 32 ocular hypertensive or glaucoma patients (24 non-Japanese and 8 Japanese) with
baseline 8 AM IOP ≥22 mmHg. IOP was evaluated every 2 hours with exception of 2AM at baseline and
day 14 of each study period.
Results: After washout, 30 subjects (7 Japanese) were treated. Baseline IOP ranged from 16.7 mmHg
(8PM & 4AM) to 23.3 mmHg (8AM). Statistically significant IOP reduction was observed at all time points
for both treatments (p<0.0001): TAP ranged from 3.1 mmHg at 2 hours postdose (10AM) to 4.8 mmHg
at 24 hours (8AM), and TAP+LAT ranged from 3.9 mmHg at 2 hours (10AM) to 6.6 mmHg at 6 hours
postdose (2PM). Fluctuation (mean difference in max and min IOP reduction over 24 hours) was lower
for TAP (1.7 mmHg) versus TAP+LAT (2.7 mmHg). Least square mean difference in 24-hour IOP of 1.1
mmHg (TAP+LAT 5.4 vs. TAP 4.3 mmHg) was statistically significant (p=0.0037, 2-sided). Treatment-
related AEs experienced by ≥20% of subjects were conjunctival hyperemia, photophobia, corneal
staining, and corneal thickness increase. IOP reduction and safety were comparable in Japanese and
non-Japanese.
Conclusion: TAP significantly lowered IOP during both day and night-time hours. TAP + LAT provided
additional IOP reduction over TAP alone. Magnitude of IOP reduction observed reflected the lower
baseline values; greater IOP reductions have been observed with TAP and TAP+LAT in a previous clinical
trial with 8AM baseline of ≥26 mmHg.

Abstract.ControlNumber:220

Abstract.Title:Excimer Laser Trabeculostomy (ELT) Clinical Update 2011

PrimaryAuthor.AuthorBlock:

Michael S. Berlin, Lea Kleineberg, Ulrich Giers, Richard Stodtmeister. Glaucoma Institute of Beverly Hills,
Los Angeles, CA, Augenklinik Detmold, Detmold, Germany, W.G. Kerckhoff-Institut, Dresden, Germany

Topic.Topic1:Trabecular Meshwork/Outflow
Abstract.Abstract1:

Purpose: To report Excimer Laser Trabeculostomy (ELT) 3 & 5 year effects on IOP and medication
requirements in phakic, pseudophakic, and combined with lensectomy patients, and to review
Pneumatic Canaloplasty, a secondary effect of ELT.
Methods: In a nonrandomized [one site] clinical trial, 80 eyes underwent ELT. 32 eyes of 32 phakic
patients (group 1) and 15 eyes of 15 pseudophakic patients (group 2), underwent ELT surgery alone. 33
eyes of 33 phakic patients underwent combined ELT with cataract surgery (group 3). A fiberoptic probe
was introduced through a paracentesis to contact the TM using a non-thermal, 308 nm xenon-chloride,
excimer laser on one eye per patient to excise the TM, the juxtacanalicular TM and the inner wall of
Schlemm’s canal.
Results: After 3 years, in group 1, mean preoperative IOP was 27.72 ± (5.95) mmHg with an average of
2.44 (± 1.27) topical medications. Mean postoperative IOP was 15.89 (± 3.29) at 3 years. IOP-lowering
medications were reduced to 0.21 (± 0.40). In group 2, mean preoperative IOP was 26.73 (± 6.360)
mmHg with an average of 2.93 (± 1.33) topical medications. Mean postoperative IOP was 14.10 (± 3.87)
at 3 years. IOP-lowering medications were reduced to 0.67 (± 0.62). In group 3, mean preoperative IOP
was 21.03 (± 4.36) mmHg with an average of 1.47 (± 0.72) topical medications. Mean postoperative IOP
was 13.16 (± 1.46) at 3 years. Medications were reduced to 0.45 (± 0.60). During ELT surgery, bubble
expansion was observed at adjacent ELT sites.
Discussion: The gas created during photoablation of TM tissue by the excimer laser forms bubbles
within the tissue. Bubble expansion from adjacent holes implies fluid/gas flow and patency into
Schlemm’s canal. Pneumatic canaloplasty is presumed to dilate Schlemm’s canal and the adjacent
collector channels resulting in a decrease of IOP adjunctive to the TM perforations.
Conclusion: ELT is a minimally invasive, safe and effective technique for the long-term treatment of
open-angle glaucoma which lowers IOP by increasing the outflow of aqueous fluid while reducing
medication requirements.
References:
Berlin M, et al. : Excimer Laser Trabeculostomy: Normalizing IOP and Restoring Physiologic Outflow in
Glaucoma, Glaucoma Today (2009).

Abstract.ControlNumber:221

Abstract.Title:A Randomized Trial of Brimonidine versus Timolol in Preserving Visual Function: Results
from the Low-pressure Glaucoma Treatment Study

PrimaryAuthor.AuthorBlock:

Theodore Krupin, Jeffrey M. Liebmann, David S. Greenfield, Robert Ritch, Stuart Gardiner. Northwestern
University Feinberg School of Medicine, Chicago, IL, New York University School of Medicine, New York,
NY, University of Miami Miller School of Medicine, Palm Beach Gardens, FL, New York Eye and Ear
Infirmary, New York, NY, Devers Eye Institute, Portland, OR

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials
Abstract.Abstract1:

ABSTRACT
Purpose: To compare the alpha2-adrenergic agonist brimonidine tartrate 0.2% to the beta-adrenergic
antagonist timolol maleate 0.5% in preserving visual function in low pressure glaucoma.
Design: Randomized, double-masked, multicenter clinical trial.
Methods: Exclusion criteria included untreated intraocular pressure (IOP) >21 mmHg, visual field (VF)
mean deviation worse than -16 decibels, or contraindications to study medications. Both eyes received
twice-daily monotherapy randomized in blocks of seven (4 brimonidine:3 timolol). Standard automated
perimetry and tonometry were performed at four-month intervals. Main outcome was VF progression in
either eye defined as the same three or more points with a negative slope >-1 db/year at P< 5%, on
three consecutive tests, assessed by pointwise linear regression. Secondary outcome measures were
progression based on glaucoma change probability maps (GCPM) of pattern deviation and the 3-
omitting method for pointwise linear regression.
Results: Ninety-nine patients were randomized to brimonidine and 79 to timolol. Mean (±SE) months of
follow-up for all patients was 30±2. Statistically fewer brimonidine treated patients (9, 9.1%) had visual
field progression by pointwise linear regression than timolol-treated patients (31, 39.2%, log-rank 12.4,
P=0.001). Mean treated IOP was similar for brimonidine- and timolol-treated patients at all time points.
More brimonidine-treated (28, 28.3%) than timolol-treated (9, 11.4%) patients discontinued study
participation because of drug-related adverse events (P=0.008). Similar differences in progression were
observed when analyzed by GCPM and the 3-omitting method.
Discussion: Low-pressure glaucoma patients treated with brimonidine 0.2% who do not develop ocular
allergy are less likely to have field progression than patients treated with timolol 0.5%.
Conclusion: The results of this trial suggest that additional research to investigate IOP-independent
disease mechanisms and treatment possibilities for glaucoma is warranted.

Abstract.ControlNumber:224

Abstract.Title:

Safety of Trabecular Bypass Stent Implantation in > 300 Eyes with Open Angle Glaucoma

PrimaryAuthor.AuthorBlock:

Jonathan S. Myers, L. Jay Katz. Wills Eye Institute, Philadelphia, PA, Wills Eye Institute, Philadelphia, PA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To evaluate safety of a trabecular micro-bypass stent in > 300 eyes with open-angle
glaucoma (OAG).
Methods: Data from a prospective, randomized US IDE study of stents implanted during cataract
surgery in mild-moderate OAG were evaluated in conjunction with other clinical trials including stent
implantation in more advanced glaucoma.[1],[2] Of 364 total stent implants in trials in and outside US,
safety data were available on 306 through 12 months or later. Evaluations included BCVA,
pachymetry, visual fields, slit-lamp and ophthalmoscopic examination, and adverse events.
Results: In the US IDE randomized trial of phaco + stent (117 eyes) vs. phaco alone (123 eyes), 2-year
BCVA was 20/40 or better in 93% of treatment vs. 91% of control eyes. Pachymetry increased by > 50
μm in 3% of treatment and 2% of control eyes. Mean deviation increased greater than 2 decibels in
16% of treatment vs. 15% of control eyes. The most frequent postoperative adverse events included
iritis (1% treatment vs. 5% control), visual disturbance (3% treatment vs. 7% control), IOP increase (4%
treatment vs. 7% control) and posterior capsular opacification (6% treatment vs. 10% control). Of the
total 364 stent eyes, the most frequent adverse events were IOP increase (12%), stent obstruction
(7%) and stent malposition (6%). Surgical interventions to treat malposition or obstruction did not
result in loss of BCVA or other clinically important adverse event.
Discussion: Overall long-term safety of iStent in conjunction with cataract surgery was similar through
2 years vs. cataract surgery alone. A low incidence of adverse events was seen in a larger series from
multiple clinical trials. The total population of 364 eyes with this stent is sufficient to detect events
occurring at a rate of 1 percent or more.
Conclusions: These data well characterize safety of this stent in OAG.

References:
[1]. Samuelson TW, Katz LJ, Wells JM, et al. Randomized evaluation of the trabecular micro-bypass
stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology 2010. In press.
[2]. Traverso CE, et al. iStent® trabecular micro-bypass stent for open angle glaucoma. Expert Rev
Ophthalmol 2010;5:443-450.

Abstract.ControlNumber:225

Abstract.Title:Trabeculectomy Using Collagen Matrix Implant: A Retrospective Review On 1 Year Data

PrimaryAuthor.AuthorBlock:

James M. Rouse, Steven R. Sarkisian. Dean McGee Eye Institute, Oklahoma City, OK

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To investigate the efficacy of the collagen matrix implant as a wound modulating agent in
glaucoma filtering surgery
Methods: Retrospective, consecutive case review of 24 eyes of 19 patients with primary open angle
glaucoma undergoing trabeculectomy with the ExPress mini glaucoma shunt. Collagen matrix was
implanted just before the conjunctival closure. Main outcome measures included post-operative
intraocular pressure (IOP) and post-operative complications. Secondary outcome measures include post-
operative visual acuity and need for further glaucoma surgery or medications. Surgical success was
defined as IOP greater than 5 mmHg and less than 22 mmHg with or without glaucoma medications or
greater than 20% reduction from baseline if baseline is less than 22 mmHg. Failure was defined as IOP
greater than 21 mmHg or less than 20% reduction from baseline in patients whose baseline is less than
21 mmHg.
Results: Surgical success, as defined above, was achieved in 86.4% of the cases reviewed at their
approximate 1 year follow up visit. Three eyes required the addition of glaucoma medications in the first
year of follow-up. One patient underwent 5-fluorouracil injection at 2 months. No other patient had any
antifibrotic agent intra or post-operatively. Two patients had early wound leaks successfully closed in
the few weeks. No further surgical interventions were required for any patients.
Discussion: The collagen matrix is a recent advancement in wound modulation in glaucoma filtering
surgery. This matrix helps to induce a regenerative wound healing process and due to its biodegradable
nature can act as scaffolding to form blebs resembling natural architecture rather than the thin
avascular blebs associated with antifibrotic agents. To this date, there is limited data available for
filtering surgery using the collagen matrix. This case series represents the first report of the use of
collagen matrix in the US with one year follow up.
Conclusions: The collagen matrix is a relatively safe and effective method for wound modulation in
glaucoma filtration surgery.

Abstract.ControlNumber:226

Abstract.Title:Factors Influencing The Signal Strength With Spectral-Domain Optical Coherence
Tomography

PrimaryAuthor.AuthorBlock:

Jay Riddle, Gina Lee, Hamid Hosseini, Elena Bitrian, Naveed Nilforushan, Joseph Caprioli, Kouros Nouri-
Mahdavi. Jules Stein Eye Institute, Los Angeles, CA

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Purpose: To determine factors affecting signal strength (SS) with spectral-domain optical coherence
tomography (SD-OCT).
Methods: Fifty-six eyes of 32 patients from the UCLA OCT Imaging Study were included. Eyes with open-
angle glaucoma or glaucoma suspects meeting the following criteria were prospectively enrolled:
reliable fields with MD >-12.0 dB, age >30 years, best corrected visual acuity >20/80, spherical refractive
error less than 8.0 D and astigmatism <3 D, no other retinal or neurological diseases and no prior
incisional surgery other than cataract extraction. Eligible patients underwent a full eye exam including
autorefractometry, biometry with IOLMaster, and disc and retinal nerve fiber layer (RNFL) OCT imaging
(Optic disc Cube 200x200, Cirrus OCT) by a single technician. Linear regression analyses correcting for
the correlation of the two eyes of the same subject were performed to determine factors influencing SS
on OCT images.
Results: Signal strength ranged from 6 to 10 (mean ± SD: 8.01 ± 0.79). On univariate analyses, older age
(p =0.002), higher central corneal thickness (CCT; p=0.025), higher IOP (p=0.034), longer axial length
(p=0.117), and pseudophakia (p=0.145) were predictive of a lower SS. Only age (p<0.001) and axial
length (p=0.012) were associated with a lower SS on multivariate analyses while CCT approached
statistical significance (p=0.077). The effect of age did not change after adjusting for LogMAR visual
acuity or lens status. Severity of glaucoma was not a predictive factor for a poorer SS on multivariate
analyses (p=0.684 for mean deviation).
Discussion: Older age and longer axial length and, to a lesser extent, CCT are the major determinants for
lower image quality with SD-OCT. The age influence does not seem to be related to media opacity.
However, the role of media opacity needs to be further investigated. Conclusion: SD-OCT image quality
tends to be worse in older patients especially those with higher degrees of myopia. This finding has
clinical implications since lower SS has been associated with thinner RNFL measurements.

Abstract.ControlNumber:229

Abstract.Title:Change In Intraocular Pressure After Cataract Extraction In The Observation Group Of The
Ocular Hypertension Treatment Study (ohts)

PrimaryAuthor.AuthorBlock:

Steven L. Mansberger, Mae O. Gordon, Henry Jampel, Anjali Bhorade, James D. Brandt, Bradley S.
Wilson, Michael A. Kass. Devers Eye Institute, Portland, OR, Washington University School of Medicine,
St. Louis, MO, John Hopkins University, Baltimore, MD, Washington University School of Medicine, St.
Louis, MO, University of California, Davis Eye Center, Davis, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To determine the change in intraocular pressure (IOP) after uncomplicated cataract
extraction in the observation group of the Ocular Hypertension Treatment Study (OHTS).
Methods: In the eye undergoing cataract surgery, we censored data after the diagnosis of POAG,
initiation of hypotensive medication and or glaucoma surgery of any kind. We defined the
preoperative IOP as the mean IOP of the three visits prior to surgery. We defined postoperative IOP as
the mean IOP on the three visits after cataract surgery. The split point for pre and post cataract
surgery was the study visit date that cataract surgery was reported i.e., surgery occurred during the
prior 6 month window.
Results: We identified 51 eyes from 33 observation participants who had cataract surgery. Compared to
participants who did not have cataract surgery, participants undergoing cataract surgery were older at
baseline (p<0.001) and were more likely to self-identify as “other” than “African American” (p=0.08) and
baseline differences were not detected for gender, IOP, CCT, or vertical cup/disc ratio. IOP (mean +/- SD)
dropped from 23.9 +/- 3.7 preoperatively to 19.6 +/- 3.6 mm Hg postoperatively (p<0.001). For the
fellow eye without extraction, the corresponding preoperative IOP was 23.6 +/- 3.1 and postoperative
IOP was 23.2 +/- 3.2.
Discussion: The OHTS observation group provides an ideal setting for assessing the impact of cataract
surgery on IOP in ocular hypertension patients. We found an immediate mean reduction in IOP of 4
mmHg which appeared sustained for about 30 months.
Conclusions: Cataract surgery in ocular hypertension patients reduces intraocular pressure.
References: None

Abstract.ControlNumber:232

Abstract.Title:

Anterior Chamber Depth, Iridocorneal Angle Width, And Intraocular Pressure Changes After
Uneventful Phacomulsification In Narrow Versus Open Angle Eyes

PrimaryAuthor.AuthorBlock:

Guofu Huang, Eduardo Gonzalez, Pai-Huei Peng, Thidarat Leeungurasatien, Roland Lee, Shan Lin. San
Francisco School of Medicine,University of California, San Francisco, CA, Shi-Kong Wu Ho-Su Memorial
hospital, Taipei, Taiwan, University of California,San Francisco, San Francisco, CA, San Francisco School
of Medicine,University of California,, San Francisco, CA

Topic.Topic1:Imaging of Anterior Segment

Abstract.Abstract1:

Title:Anterior chamber depth, iridocorneal angle width, and intraocular pressure changes after
uneventful phacomulsification in narrow versus open angle eyes.
Purpose: To investigate the changes in anterior chamber angle using AS-OCT and its correlation with
intraocular pressure after phacoemulsification with intraocular lens implantation in narrow and open
angle eyes.
Methods: In this prospective study, all subjects underwent phacomulsification with foldable lens
implantation. Images of the anterior segment were obtained using a commercially available AS-OCT
device under dark conditions. Mean anterior chamber angle grading ≤II was considered as narrow angle
using the Shaffer grading system . Data were recorded preoperatively, and at 10 days, 1 month, 3
months, and 6 months after surgery. Anterior chamber depth (ACD) and angle opening distance at
500μm (AOD500) anterior to the scleral spur were used to evaluate anterior chamber configuration
before and after surgery. Correlation was evaluated between angle width and percent IOP reduction
using Pearson two-tailed t test.
Results: Data were collected from 63 eyes that underwent cataract surgery. Twenty nine eyes were
determined to be narrow angle . Before surgery the mean AOD500 and ACD in the narrow angle (NA)
group were 210.93±113.63μm and 2.25±0.29 mm, respectively. At 6 months after surgery, the mean
AOD500 and ACD in the NA group were 385.71±103.91μm and 3.76±0.22 mm, respectively. Anterior
chamber angle widening postoperatively was approximately 50% in the NA group and 30% in control
group. The postoperative IOP was reduced significantly in both groups. The amount of IOP reduction
was 2.61±1.80 mmHg (16.65%) in the NA group, 1.41±2.13 mmHg (9.61%) in the control group, which
were significantly different between the groups (p=0.029). We also found weak but significant
correlations between IOP decrease and angle widening (r=0.386,p=0.039) in the NA group.
Conculsions: Postoperative reduction in IOP was proportional to the increase in angle width in narrow
angle eyes. Phacoemulsification with intraocular implantation may widen the angle to lessen angle
crowding in cataract eyes with narrow angle configuration.

Abstract.ControlNumber:234

Abstract.Title:Cost Consequence Analysis of the Tube versus Trabeculectomy Trial

PrimaryAuthor.AuthorBlock:

Pratap Challa, Santanu K. Datta, Steven J. Gedde, William J. Feuer, Joyce C. Schiffman. Duke University,
Durham, NC, Duke University, Durham, NC, Bascom Palmer Eye Institute, Miami, FL

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Purpose: To report a cost consequence analysis of the first 5-years of follow-up in the Tube Versus
Trabeculectomy (TVT) Study
Methods: Cost consequence analysis
Design: Multicenter randomized clinical trial
Setting: 17 Clinical Centers
Study Population: Patients 18 to 85 yrs old with prior trabeculectomy, cataract extraction with IOL, or
both and uncontrolled glaucoma on MTMT with intraocular pressure >18 mm Hg and <40 mmHg
Interventions: 350-mm2 Baerveldt glaucoma implant or trabeculectomy with mitomycin C 0.4 mg/ml for
4 minutes
Main Outcome Measures: Cost of glaucoma medications and surgical interventions
Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the
trabeculectomy group. The cost of initial surgical treatment was $3,513 and $2,691 for the tube and
trabeculectomy groups, respectively. Patients in both treatment groups had very similar follow-up time
until failure: 50 and 49.5 months for tube and trabeculectomy, respectively. The monthly cost of
glaucoma medications (mean ± SD) was $35.87 ± 38.01 in the tube group and $20.29 ± 53.88 in the
trabeculectomy group. The total cost for glaucoma reoperations was $22,819 and $64,622 in tube and
trabeculectomy groups, respectively. Procedures to manage complications resulted in a total cost of
$126,587 and $45,231 in tube and trabeculectomy groups, respectively. The total cost of medical and
surgical treatment per patient was $2,878 and $1,839 for tube and trabeculectomy groups, respectively.
Discussion: The surgical cost of tube shunt surgery is higher than trabeculectomy and supplemental
medical therapy was more expensive after tube surgery compared with trabeculectomy. Reoperations
to manage complications were more costly after tube placement, and reoperations for glaucoma
incurred a greater cost following trabeculectomy. The total cost of all medical and surgical treatment
was higher for tube surgery compared with trabeculectomy.
Conclusions: Both procedures yield similar effectiveness but aggregating the costs of medical and
surgical treatment, tube shunt surgery was more expensive than trabeculectomy with MMC during the
first 5 years of follow-up in the TVT Study.
References: None
Abstract.ControlNumber:235

Abstract.Title:

Differentially Expressed Proteins in the Aqueous Humor of Primary Congenital Glaucoma

PrimaryAuthor.AuthorBlock:

Deepak P. Edward, Rachida Bouhenni, Sami Al Shahwan, Jose Morales, Bassam Wakim, Anthony
Chomyk, Fowzan AlKuraya. Summa Health System, Akron, OH, King Khaled Eye Specialist Hospital,
Riyadh, Saudi Arabia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, Medical College of
Wisconsin, Milwaukee, WI, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Topic.Topic1:Other

Abstract.Abstract1:

Introduction: Primary Congenital Glaucoma (PCG) is an autosomal recessive disease and is characterized
by abnormal development of the anterior chamber angle. Although, PCG has been linked to several
genetic loci, the role of genes at these loci, their encoded or related proteins play in the pathophysiology
of PCG is not known. The goal of this study is to identify altered proteins in PCG aqueous humor (AH)
that may help in understanding the pathophysiology of PCG.
Methods: Tryptic digests of the complex mixtures of proteins in AH were analyzed using Liquid
Chromatography/ Mass Spectrometry (LC-MS/MS). Proteins were identified using the UniProt database.
The proteomes of AH in PCG (n=7) and patients undergoing cataract surgery as control (n=4) were
compared and analyzed statistically using stringent filtering criteria and validated by Western blotting.
Results: Apolipoprotein A-IV (APOA-IV), Albumin and Antithrombin 3 (ANT3) were detected at
significantly higher levels in PCG AH compared to control, whereas Transthyretin (TTR), Prostaglandin-
H2 D-isomerase (PTGDS), Opticin (OPT) and Interphotoreceptor Retinoid Binding Protein (IRBP) were
detected at significantly lower levels.
Discussion: Many of these altered AH proteins in PCG play a role in retinoic acid (RA) binding/transport
suggesting that the pathologic changes in PCG during development could be influenced by the
availability of RA in the anterior chamber.
Conclusion: The differentially expressed proteins identified in this study represent potential biomarkers
for PCG and could be postential targets for pharmacologic manipulation.
References:
1.Bejjani, B.A et al. 1998. Mutations in CYP1B1, the gene for cytochrome P4501B1, are the predominant
cause of primary congenital glaucoma in Saudi Arabia. Am J Hum Genet 62, 325-333.
2.Davidsson, etl al, 2006. Proteome studies of CSF in AD patients. Mech Ageing Dev 127, 133-137.
3. Coca-Prados, M., Escribano, J., 2007. New perspectives in aqueous humor secretion and in glaucoma:
the ciliary body as a multifunctional neuroendocrine gland. Prog Retin Eye Res 26, 239-262.

Abstract.ControlNumber:236

Abstract.Title:Evaluation of the Canadian Glaucoma Guidelines
PrimaryAuthor.AuthorBlock:

Enitan A. Sogbesan, Yvonne M. Buys, Paul E. Rafuse, Karim F. Damji. University of Alberta, Edmonton,
AB, Canada, University of Toronto, Toronto, ON, Canada, Dalhousie University, Halifax, NS, Canada

Topic.Topic1:Other

Abstract.Abstract1:

Introduction:
To evaluate awareness and acceptance of the Canadian Glaucoma Guidelines (CGGs).
Methods:
An online questionnaire of the CGGs was sent to members of the Canadian Ophthalmological Society
(COS). Data was collated and analyzed.
Results:
207 (26% of COS) responded. Majority were in comprehensive adult practices. 57% of respondents were
community based. 47% were in practice 20+years and 18% < 5 years.
91% were aware of the existence and 74% had read the guidelines. 81% were familiar with the
recommendations. 76% felt the CGGs are relevant to their practice. About a half (47%) felt the
recommendations will change their practice.
Agreement for most recommendations was 60 to >80% with the exception of management of combined
cataract and glaucoma where it ranged from 50 to 100%. 11% were in disagreement with one or more
recommendations.
66% identified barriers to implementation of recommendations. 80% have adequate trained personnel
for clinical work but only 47% for stereo photos and 40% for patient education.
For staging glaucoma severity, 71% were familiar with the CGGs. However, only 42% stage the disease,
47% set target pressures and 70% assess baseline data all the time.
Discussion:
There is paucity of literature assessing the knowledge and integration of guidelines. This information is
important to improve both content and dissemination of the CGGs.
Conclusions:
Most of the respondents were familiar with the CGGs and agreed with the recommendations; about a
half felt that they would change their practice. Some barriers and limitations to implementation were
identified.
References:
1. Canadian Ophthalmological Society evidence based clinical practice guidelines for the management of
glaucoma in the adult eye, Can J Ophthalmol 2009: 44
2. Quigley HA, et al. Evaluation of practice patterns for the care of open-angle glaucoma compared with
claims data: the Glaucoma Adherence and Persistency Study. Ophthalmology 2007; 114:1599-606.
3. Hertzog LH, et al. Glaucoma care and conformance with preferred practice patterns. Examination of
the private, community-based ophthalmologist. Ophthalmology 1996:1009-13.

Abstract.ControlNumber:237
Abstract.Title:

Cost Analysis Of Ex-press™ Versus Trabeculectomy

PrimaryAuthor.AuthorBlock:

Hussain Y. Patel, Lilach Drori, Graham E. Trope, Yvonne Buys. University of Toronto, Toronto, ON, Canada

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: Cost constraints have the ability to obstruct the introduction of new technology. This study
aimed to compare the cost differences between Ex-PRESS and trabeculectomy.
Methods: Prospective, randomised, non-masked, comparative study. 40 patients were enrolled: 20 each
in Ex-PRESS and trabeculectomy. Surgical cost difference was analysed using the vendor list price with
only differences between operations analysed. 1 year post-operative cost difference was analysed for
cost of follow-up visits, additional procedures and medication.
Results: Insertion of the Ex-PRESS device had a net surgical cost of CAN $1005 greater than
trabeculectomy due to the cost of the Ex-PRESS device ($900) and viscoelastic ($129) minus the cost of
the disposable superblade ($24) used for trabeculectomy. Interim analysis of patients with 1 year follow
up data (n = 15) revealed no significant difference in mean total post-operative costs ($738 ± $627 vs
$574 ± $286, p = 0.4), cost of follow up visits ($362 ± $187 vs $334 ± $83, p = 0.7), additional procedures
($259 ± $363 vs $160 ± $206, p = 0.5) or medication ($104 ± $114 vs $68 ± $56, p = 0.4) for Ex-PRESS vs
trabeculectomy respectively. For our department the incremental cost of Ex-PRESS would be +/-
$200,000, and for the province of Ontario +/- $1,800,000.
Discussion: The Ex-PRESS device has been developed as an alternative filtration procedure to
trabeculectomy. Two previous publications have compared the efficacy and safety of ExPRESS to
trabeculectomy.1, 2 To our knowledge, no previous reports have compared the cost difference between
the 2 operations.
Conclusion: This study demonstrates that the Ex-PRESS device is associated with greater surgical costs
compared to trabeculectomy. However, based on interim data there does not appear to be a significant
difference in post-operative costs.
References:
1.De Jong LA. The Ex-PRESS glaucoma shunt vs trabeculectomy in open angle glaucoma: a prospective
randomized study. Advances in Therapy 2009; 26:336-45.
2.Maris PJ, Ishida K, Netland PA. Comparison of Trab with Ex-PRESS miniature glaucoma device
implanted under scleral flap. J Glaucoma 2007 Jan; 16:14-9.

Abstract.ControlNumber:238

Abstract.Title:The Impact of Automated Reminders Linked to a Personal Health Record on Adherence
with Glaucoma Medications: The Automated Dosing Reminder Study (ADRS)

PrimaryAuthor.AuthorBlock:
Michael V. Boland, Dolly S. Chang, Travis C. Frazier, David S. Friedman. Johns Hopkins University,
Baltimore, MD, Madigan Army Medical Center, Tacoma, WA

Topic.Topic1:Other

Abstract.Abstract1:

Introduction:
Interventions proposed to improve adherence with glaucoma medications should ideally be simple and
inexpensive given the scope of the problem and lack of resources for personnel-intensive approaches.
We linked automated, telecommunication-based reminders to a personal health record and assessed
the impact on adherence.
Methods:
Subjects taking once daily eye drops were recruited from a university-based glaucoma practice. Those
that agreed to participate underwent a 3 month period during which their use of eye drops was
recorded electronically (MEMS, AARDEX Group). Adherence was assessed by including doses taken
within 4 hours of the median dose time and excluding doses two weeks after the initial visit and two
weeks before the followup visit. Subjects found to have taken less than 75% of doses correctly were
randomized either to no intervention or to receiving daily, automated reminders via text or voice
message (Memotext). The messages were scheduled and associated with a particular medication using a
Personal Health Record (PHR) established for each subject (HealthVault, Microsoft Inc.)
Results:
429 subjects were enrolled in the ADRS. Of these, 47 were poorly adherent after 3 months and were
randomized to either the control or intervention group. The baseline adherence rates for these two
groups were similar (49% and 51% respectively, p=0.7) Using an intention to treat analysis, the
adherence rate in the control group did not change from baseline (p=0.8) while the intervention group
improved to 67% (p=0.002).
Conclusions:
The combination of a PHR and telecommunication-based reminders successfully increased adherence
with glaucoma medications in a group determined to have poor adherence. The method used in the
ADRS to improve adherence is practical and patient-centric. Work should now focus on making this
intervention available to patients and their families.
References:
1. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored
electronically the Travatan Dosing Aid study. Ophthalmology 2009;116:191-9.

Abstract.ControlNumber:239

Abstract.Title:In Vivo Imaging of RGC Uptake of Activatable Cell-Penetrating Probes for Imaging
Apoptosis in Rodents

PrimaryAuthor.AuthorBlock:
Edward M. Barnett, Xudong Qiu, James R. Johnson, David Piwnica-Worms. Washington University in St.
Louis, St. Louis, MO, Washington University in St. Louis, St. Louis, MO

Topic.Topic1:Other

Abstract.Abstract1:

Introduction:
Previously, we reported the in vitro and in vivo validation of first (TcapQ) and second generation (KcapQ)
activatable peptide probes developed for imaging apoptosis through effector caspase activity. 1,2,3
Although the second generation probe, with its modified cell penetrating sequence, displays a lower in
vitro toxicity compared with TcapQ, the effect of this alteration on cellular uptake has yet to be
demonstrated. Using in vivo imaging with a confocal scanning laser ophthalmoscope, we compared the
RGC uptake of these probes in rats.
Methods:
Both probes consist of a cell-penetrating peptide conjugated to an effector caspase recognition
sequence (DEVD) that is flanked by a fluorophore (reporter). To enable in vivo imaging using the HRA-II
(Heidelberg Engineering), Alexa-Fluor 488 was utilized as the fluorophore. Since these experiments
focused on uptake rather than activation, unquenched probe was used (Tcap488, Kcap488). Following
intravitreal injection of probe in rats, the retina was imaged in vivo to assess RGC uptake and labeled
cells were counted using Image J software.
Results:
Using similar concentrations (~175 uM) the Tcap488 probe resulted in a greater than 3-fold increase in
cellular uptake as compared with Kcap488 as demonstrated by cell counts from HRA-II images of rat
retinae. This finding was consistent across the time points examined. The advantage of Tcap over Kcap
remained even when the concentration of Kcap used was increased as much as 10-fold.
Discussion:
While the second generation probe (KcapQ) demonstrated potential advantages over the first
generation probe (TcapQ) in terms of sensitivity to activated effector caspases, quenching efficiency,
and reduced cellular toxicity in in vitro studies, it shows reduced cellular uptake as assessed by in vivo
imaging.
Conclusions:
Reduced cellular toxicity of cell-penetrating probes for imaging in vivo RGC apoptosis may come at the
expense of reduced cellular uptake.
References:
1
 Bullok K, Piwnica-Worms D. J Med Chem. 2005; 48: 5404-7
2
 Maxwell D, et. al. Bioconjugate Chem. 2009; 20:702-709.
3
 Barnett EM et al. Proc Natl Acad Sci USA. 2009; 106(23): 9391-9396.

Abstract.ControlNumber:240

Abstract.Title:Trans-Lamina Cribrosa Pressure Difference Correlated With Neuroretinal Rim Area in
Glaucoma
PrimaryAuthor.AuthorBlock:

RUOJIN REN, Ningli Wang, Jost B Jonas. Beijing Institute of Ophthalmology, Beijing Tongren Hospital,
Beijing, China, Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing, China, Medical Faculty
Mannheim of the Ruprecht-Karls-University Heidelberg, Heidelberg, Mannheim, Germany

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Purpose. To prospectively assess the relationship between trans-laminar cribrosa pressure difference
and neuroretinal rim area as morphologic surrogate of glaucomatous optic nerve damage.
Methods. The study included 22 patients with high-pressure glaucoma, 13 patients with normal-
pressure glaucoma and 17 subjects with ocular hypertension. All participants underwent a standardized
ophthalmologic examination including confocal laser scanning tomography of the optic nerve head and
computerized perimetry, and a neurologic examination including measurement of the lumbar
cerebrospinal fluid (CSF) pressure. The trans-lamina cribrosa pressure difference was calculated as
difference of intraocular pressure minus lumbar CSF pressure.
Results. Neuroretinal rim area (P=0.006; correlation coefficient r=-0.38) and mean visual field defect
(P=0.008; r=0.38) were significantly associated with trans lamina cribrosa pressure. The statistical
significance was higher (i.e. the P-value were lower) and stronger (i.e. the correlation coefficients were
higher) for the associations between rim area / visual field defect with trans lamina cribrosa pressure
difference than for the associations between rim area / visual field defect and intraocular pressure or
lumbar CSF pressure.
Conclusions, The trans-lamina cribrosa pressure difference as difference of intraocular pressure minus
lumbar CSF pressure was the main pressure parameter associated with the amount of glaucomatous
optic nerve damage. It shows the importance the CSF pressure as counter pressure against the
intraocular pressure across the lamina cribrosa of the optic nerve head may have for the pathogenesis
of glaucomatous optic neuropathy. Through the CSF pressure, glaucoma is not only an ocular disorder
but a cerebral disease.
References:
Burgoyne CF, et al. The optic nerve head as a biomechanical structure: a new paradigm for
understanding the role of IOP-related stress and strain in the pathophysiology of glaucomatous optic
nerve head damage. Prog Retin Eye Res 2005; 24:39-73

Abstract.ControlNumber:241

Abstract.Title:The Effect Of Intracameral Triesence (Triamcinolone Acetonide injectable suspension) on
Ocular Inflammation After Trabeculectomy, Tube Shunt Implantation Or Combined Trabeculectomy
With Cataract Surgery

PrimaryAuthor.AuthorBlock:
Shelly R. Gupta, Marlene R. Moster, Kathryn B. Freidl, Parul Ichhpujani, Jonathan S. Myers, Michael J.
Pro. Wills Eye Institute, Philadelphia, PA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction
Modifications of glaucoma surgery are sought to maximize success and lower morbidity. Triamcinolone
(TA) is a corticosteroid that reduces postoperative inflammation and excessive scarring1,2.
Our objective was to evaluate efficacy and safety of intracameral TriesenceTM (TA injectable
suspension) in patients undergoing trabeculectomy, tube shunt, or combined phaco/trabeculectomy.
Methods
A prospective, randomized clinical trial of 53 consecutive eligible patients from 4/2009 - 12/2010 at Wills
Glaucoma Service.
Patients underwent standard surgical technique but were randomized to receive either intracameral
Triesence or BSS. They were followed post-operative day 1, week 1, month 1, month 3, and month 6.
Outcome measures were visual acuity (VA), patient comfort, bleb appearance, IOP, lens opacities,
Triesence crystals in the anterior chamber (AC), AC inflammation, and glaucoma medication need. AC
flare was measured by the KOWA FM,500 laser flare meter. Complications and success were recorded.
Success criteria were IOP ≤ 21 mmHg and 20% IOP reduction. Failure was inability to meet above
criteria, IOP < 5 mmHg, or need for reoperation.
Results
Both arms had similar pre-op VA and IOP. There was no statistically significant difference in mean IOP
reduction in control vs. Triesence at 1 (avg IOP 14.9 mmHg vs 16.9 mmHg) or 6 (IOP 14.3 mmHg vs 14.8
mmHg) months (p=0.138, n=48 & p=0.723, n=34). There was no statistical difference in flare, AC
inflammation, comfort, or VA at month 1 between arms. At 6 months, both success and complication
rates were similar between intracameral Triesence and controls.
Discussion
Although intracameral steroid may add potency and ease compliance issues, intracameral Triesence
showed no difference in AC inflammation, flare, VA, IOP, or comfort compared to controls.
Conclusion
Intracameral use of Triesence during glaucoma surgery appears safe with similar outcomes to controls.
References
1.Gills JP, et al. Effect of intracameral triamcinolone to control inflammation following cataract surgery. J
Cat Ref Surg. 2005 Aug;31(8):1670.
2.Tham CC, et al. Intrableb triamcinolone injection after bleb-forming filtration surgery. Eye. 2006
Dec;20(12):1484-6.

Abstract.ControlNumber:242

Abstract.Title:The Effect of Selective Laser Trabeculoplasty on Intraocular Pressure after
Trabeculectomy.
PrimaryAuthor.AuthorBlock:

Michael P. Hood, Ben J. Harvey, Patrick W. Risch, James M. Rouse, Gregory L. Skuta, Steven R. Sarkisian,
Mahmoud A. Khaimi. Dean McGee Eye Institute, Oklahoma City, OK

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: To evaluate the use of selective laser trabeculoplasty (SLT) in eyes with prior trabeculectomy.
Methods: A retrospective chart review of 77 eyes of 73 patients with open angle glaucoma (OAG)
undergoing SLT after previous trabeculectomy with antifibrotics. Patients were included if they were >
18 years of age, had been diagnosed with OAG, had a history of prior trabeculectomy and had
undergone SLT therapy to 180 or 360 degrees of their trabecular meshwork. Intraocular pressure (IOP)
was measured prior to each laser and at 30-60 minutes, 1-4 weeks, 3-6 months, 6-12 months, 12-18
months, 18-24 months, 24-36 months, and 36-48 months after laser. Generalized estimating equations
were used to estimate response and adverse event probabilities while accounting for the correlation
among eye-level measures on the same subject.
Results: Mean baseline IOP prior to SLT was 19.87 ± 4.39 mmHg. A response to SLT was defined as a
decrease in IOP from baseline of greater than or equal to 20% at 3-6 months after laser. The response
rate at 3-6 months (n=58 eyes) was 36% (95% CI: 24% to 51%). Of responding eyes at 3-6 months, 12
month data was available for 9 eyes. 44% of these eyes (95% CI: 17-76%) maintained response rate to
the SLT. The only adverse events were early and late IOP spikes > 5 mmHg which was seen in 9% (95%
CI: 4-18%) and 9% (95% CI: 3-20%) of eyes respectively. These IOP spikes were transient in nature.
Discussion/Conclusion: SLT remains safe and effective for the treatment of open angle glaucoma in eyes
previously treated with trabeculectomy (36% response rate). It remains an IOP-lowering option in select
eyes that have undergone prior incisional glaucoma surgery.

Abstract.ControlNumber:243

Abstract.Title:

Glaucoma Drainage Device Exposure In Patients With Boston Keratoprosthesis.

PrimaryAuthor.AuthorBlock:

Shuchi Patel, Hana Takusagwa, Claes Dohlman, Cynthia Grosskreutz. Loyola University Medical
Ceneter/Massachusetts Eye and Ear Infirmary, Maywood/Boston, IL, Massachusetts Eye and Ear
Infirmary, Boston, MA

Topic.Topic1:Other

Abstract.Abstract1:

Introduction: Glaucoma following a Boston Keratoprosthesis (KPro) is a known occurrence.1 Therefore,
many KPro patients require a glaucoma drainage device (GDD). One complication of a GDD is tube
exposure. We did a retrospective review to see the etiologies and outcomes.
Method: A retrospective chart review of patients from the last 5 years with both a KPro and a GDD
having tube exposure.
Results: 16 patients with a total of 19 incidents of tube exposure were identified. In all cases, a BCL was
in place. 7/19 (37%) resolved without surgical intervention. 5/19 (26%) had the tube revised. 4/19 (21%)
had the tube explanted. 3/19 (16%) have stable erosions.
Discussion: It has been found that a BCL with a KPro helps prevent corneal melt. Thus, it has become a
mandatory part of care for a KPro. Anecdotally, we noted more tube erosions than are normally
reported for GDD, which is less than 5%.2 Furthermore, the erosion were typically along the edge of the
BCL, therefore likely mechanical. Literature states that tube exposures require surgical revision given a
low likelihood of resolution,3 while our review shows that many of these erosions resolve without
surgery. We propose that the mechanism of erosion with KPros and BCLs is different than those with
spontaneous erosions. Thus, the treatment should be tailored with less aggressive measures at first
since a large percentage may resolve with a change in contact lens diameter.
Conclusion: Tube erosions with a KPro and BCL are likely due, at least in part, to mechanical erosion.
Since the mechanism is different than that of other erosions, the treatment should be modified
accordingly. Our review showed a large percentage of erosions resolving without surgery. Thus, less
aggressive measures may be indicated in patients with KPros and BCLs.
References:
1. Chew HF, Ayers BD, Hammersmith KM et al. Boston keratoprosthesis outcomes and complications.
Cornea 2009 Oct;28(9):989-96.
2. Ainsworth G, Rotchford A, Dua HS et al. A novel use of amniotic membrane in the management of
tube exposure following glaucoma tube shunt surgery. Br J Ophthalmol. 2006 Apr;90(4):417-9.
3. Heuer DK, Budenz D, Coleman A. Aqueous shunt tube erosion. J Glaucoma. 2001 Dec;10(6):493-6.



Abstract.ControlNumber:244

Abstract.Title:Ophthalmic Endoscopic Surgery: Refractory Glaucoma and Beyond

PrimaryAuthor.AuthorBlock:

Ronald Leigh Fellman, Robert Noecker, Brian Francis, Jamie Brandt, Thomas C. Lee. Glaucoma Associates
of Texas, Dallas, TX, University of Pittsburgh Medical Center, Pittsburgh, PA, Doheny Eye Institute, Los
Angeles, CA, University of California Davis, Sacramento, CA, Children Hospital Los Angeles/ Doheny Eye
Institute, Los Angeles, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

Ophthalmic Endoscopic Surgery: Refractory Glaucoma and Beyond
The focus of this SIG is to examine the options for patients that have failed multiple surgical
interventions and/or have poor prognoses for conventional glaucoma surgery. It will also focus on other
uses for ophthalmic endoscopy to assist in anterior and posterior segment surgery. The panelists will
present challenging clinical cases that highlight how endoscopy can significantly enhance surgical
options and outcomes for these complex cases. Ophthalmic endoscopic surgery is an under utilized
diagnostic and therapeutic technology that may benefit glaucoma specialists, especially when dealing
with complex glaucomas that have not responded to conventional therapy. The ability to visualize
anterior segment anatomy in the operating room under adverse conditions with the endoscope is an
additional benefit that enhances clinical care. Consideration will be given to existing surgical and laser
interventions as well as new techniques that can be used in these challenging cases.

Abstract.ControlNumber:245

Abstract.Title:Response to Initial Selective Laser Trabeculoplasty (SLT) Is Not Predictive of Response to
Repeat SLT

PrimaryAuthor.AuthorBlock:

Ben J. Harvey, Michael P. Hood, Patrick W. Risch, James M. Rouse, Mahmoud A. Khaimi, Gregory L.
Skuta, Steven R. Sarkisian. Dean McGee Eye Institute, Oklahoma City, OK

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: To evaluate the use of repeat selective laser trabeculoplasty (SLT) in patients with previous SLT
treatment and determine if response to initial SLT is predictive of response to repeat SLT.
Methods: A retrospective chart review of 115 eyes of 86 patients with open angle glaucoma (OAG) or
ocular hypertension (OHT) who underwent repeat 180 or 360 degree SLT therapy after failing an initial
SLT treatment despite maximal medical management. Patients were included if they were > 18 years of
age, diagnosed with OAG or OHT and had undergone repeat SLT therapy. No SLT-naive trabecular
meshwork was included in the repeat SLT analysis. Patients were excluded if they underwent other
glaucoma procedures between SLT treatments or if they were lost to follow-up after laser therapy.
Intraocular pressure (IOP) was measured prior to each laser and 30-60 minutes, 1-4 weeks, 3-6 months,
6-12 months, 12-18 months, 18-24 months, 24-36 months, and 36-48 months after laser treatment.
Generalized estimating equations were used to estimate response and adverse event probabilities while
accounting for the correlation among eye-level measures on the same subject.
Results: Mean baseline IOP prior to initial (SLT1) and repeat SLT (SLT2) was 22.54 ± 5.12 mmHg and
21.68 ± 3.38 mmHg, respectively. A response to SLT was defined as an IOP decrease of > 20% from
baseline at 3-6 months after laser. The percentage of eyes responding to SLT1 was 54% (95% CI: 42%-
65%) was similar to the percentage responding to SLT2 which was 56% (95% CI: 44%-67%) (p=0.96).
Responding to SLT1 was not predictive of responding to SLT2 (p=0.87). The only adverse events were
early (30-120 minutes) and late (1-4 weeks) IOP spikes after laser in both groups. Early IOP spikes
occurred in
14% (95% CI: 8%-23%) of SLT1 and 3% (95% CI: 1%-9%) of SLT2. Late IOP spikes occurred in 3% (95% CI:
1%-9%) of SLT1 and 9% (95% CI: 5%-17%) of SLT2.
Discussion/Conclusion: Repeat SLT therapy is safe and effective in the treatment of OAG and OHT in
patients who underwent prior SLT therapy. Its success rates are similar to those seen after initial SLT
therapy although response to initial SLT is not predictive of response to repeat SLT.

Abstract.ControlNumber:246

Abstract.Title:Medication Adherence In Pediatric Glaucoma Is Influenced By Parental Health Literacy
Not Dosing Frequency

PrimaryAuthor.AuthorBlock:

Rebecca B. Freedman, Alice Lin, Sarah K. Jones, Sharon F. Freedman, Alan L. Robin, Kelly W. Muir. Duke
Eye Center, Durham, NC, University of Maryland, Baltimore, MD

Topic.Topic1:Other

Abstract.Abstract1:

Introduction: Medication adherence is well described for adults with glaucoma but not for children.
Parental educational background is associated with adherence to amblyopia therapy,1 and poor health
literacy is related to poor glaucoma medication adherence in adults.2 This study assesses glaucoma
medication adherence in children, hypothesizing that poor parental health literacy and drop instillation
by the child are associated with poor adherence.
Methods: This prospective observational study enrolled sequential pediatric glaucoma patients.
Parent(s) reported who was responsible for drop instillation, took the Rapid Assessment of Adult
Literacy in Medicine (REALM), a test of health literacy, and received the Medication Event Monitoring
System (MEMS) cap to record drop instillation. At study completion, companion software calculated
percent adherence (proportion of prescribed doses taken), dosing errors (# over- or under-dosing events
per day), and proportion of doses taken on schedule (within +25% of prescribed dosing interval).
Students’ t test and linear regression were applied.
Results: Included were 46/50 enrolled children (Feb.-Sept.2009) who used MEMS for >30 days. Median
age was 10 years (range 5-17). Percent adherence ranged from 43-107% (mean 93+12); it was not
statistically associated with age (slope 0.09 + 0.52, p=0.86), or whether parent vs. child instilled drops
(92+13 vs 96+4, resp., p=0.20), but decreased with lower literacy of the parent (slope 0.62+0.24,
p=0.01). Dosing errors for medications prescribed qd vs. bid were similar (3.3 vs. 2.9, p=0.66). Proportion
of doses taken on schedule ranged from 7-100% (mean 73+24, median 79), and was better when parent
vs. child instilled drops (76+24 vs. 64+24, resp., p<0.05).
Discussion: Time-dependent glaucoma medication adherence was better when the parent was
responsible for drop instillation. Overall adherence declined as did parental health literacy.
Conclusions: Children of parents with poor health literacy are vulnerable to poor medication adherence;
efforts to reduce barriers to adherence may improve outcomes.
References:
1. Loudon SE et al. IOVS 2006;47(10):4393-400.
2. Muir KW et al. AJO 2006;142(2):223-6.

Abstract.ControlNumber:247

Abstract.Title:Development of a Glaucoma Specific Utilty Elicitation Instrument

PrimaryAuthor.AuthorBlock:

Steven Kymes, Colleen Peters, Kathleen Beusterien, Sameer Kotak, Andreas Pleil. Washington University
School of Medicine, Saint Louis, MO, Oxford Outcomes, Bethesda, MD, Pfizer, Inc., New York, NY, Pfizer,
New York, NY

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: The utility is a metric ranging from 0 (death) to 1 (perfect health) describing preference for
a health state. A utility of 0.65 for blindness would indicate that being blind is 35% worse than being in
perfect health. We developed a short interview based upon the National Eye Institute’s Visual Function
Questionnaire (NEI-VFQ) to estimate utility loss from POAG progression. Methods: We identified items
from the NEI-VFQ responsive to differences in mean deviation in a cross sectional sample of 1,677
people enrolled in OHTS and 99 people with more advanced disease. Twelve items were identified and
incorporated into a conjoint interview administered to 48 people with POAG. From these results we
identified 5 items of greatest importance (the peripheral vision item was added separately). We then
constructed an interview using standard gamble and visual analog scale which was administered to 404
community based participants to elicit utlility weights for these items. Results: The five attributes most
important to people with glaucoma were reading, driving, leaving home, requiring help with activities
and the ability to accomplish tasks. Loss of all of these functions and peripheral vision had a disutilty of
0.27. In the Table we detail the utility loss associated with each item. Discussion: There is measurable
loss of utility associated with modest loss in visual function. However, determining how this is
associated with glaucoma progression remains to be seen and will be part of our validation of the
instrument.Conclusions: We have developed a glaucoma specific utility elicitation instrument based
upon the NEI-VFQ. Further validation will be necessary to determine its usefulness to health policy
makers and clinicians.




Abstract.ControlNumber:248

Abstract.Title:Development And Testing Of A Novel Head-mounted, Eye-tracking Perimeter With Virtual
Reality Visor

PrimaryAuthor.AuthorBlock:
Dariusz Wroblewski, Brian A. Francis, Alfredo Sadun, Ghazal Vakili, Vikas Chopra. BioFormatix, Inc., San
Diego, CA, USC-Doheny Eye Institute, Los Angeles, CA

Topic.Topic1:Perimetry and Functional Testing

Abstract.Abstract1:

Purpose: To report on the development and preliminary evaluation of a portable, head-mounted
perimeter that incorporates novel eye-tracking with visual grasp testing.
Methods: VirtualEye is a light-weight perimeter that uses a customized, head-mounted virtual reality
visor connected to a laptop computer. The device performs the equivalent of full threshold 24-2 visual
field testing in two modes: (1) manual (subjective), with patient response registered with a mouse click,
and (2) a newly-developed visual grasp (objective), where the on-board eye tracker senses an
appropriate change in gaze as evidence of target acquisition.
Results: 9 participants with normal visual fields and 25 participants with mild to severe visual field
deficits due to glaucoma and neuro-ophthalmic disorders underwent VirtualEye testing in manual and
visual grasp modes, and the results were compared to same-day testing using standard Humphrey Field
Analyzer (HFA II). Point-by-point comparison between the results obtained with different modalities
indicated: (1) a systematic shift (of 4-6 dB) towards lower sensitivities for the VirtualEye device, (2)
negligible systematic differences between measurements taken in visual grasp and manual modes, and
(3) the average standard deviation of the difference distributions of about 5 dB (for three pair-wise
comparisons). A brief questionnaire addressing usability issues showed a preference by participants for
the head-mounted perimeter due to improved comfort and ease of use.
Discussion: Preliminary clinical results indicate that our newly-developed, portable, head-mounted
perimeter with novel eye-tracking with visual grasp testing had a high level of participant acceptance,
and the testing was sufficiently accurate but slightly less sensitive compared with standard perimetry.
Conclusion: With contained test environment and high level of comfort and mobility for the participants,
the VirtualEye perimeter may prove to be useful for out-of-clinic and population screening applications,
as well as, available for persons with poor hand-eye coordination or those with inability to perform
standard office testing in a seated position.

Abstract.ControlNumber:249

Abstract.Title:Optic Nerve Head Vessel Caliber Changes In Glaucoma

PrimaryAuthor.AuthorBlock:

Richard K. Lee, Dyani A. Loo, Lauren A.B. Hodgson, Tien Y. Wong, David S. Greenfield, Jonathan G.
Crowston. Bascom Palmer Eye Institute, Miami, FL, Centre for Eye Research Australia, East Melbourne,
Australia, Bascom Palmer Eye Institute, Palm Beach Gardens, FL

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:
Purpose/Background: Vascular factors have been suggested to impact the risk for development and
progression of glaucomatous optic nerve head (ONH) and visual field changes. The purpose of this study
is to determine if glaucoma is associated with peri-papillary vascular changes compared to normal eyes.
Methods: Normal eyes (n=38) had no history of ocular disease except cataract, IOP ≤ 21 mmHg, had a
normal ONH appearance based upon review of stereo disc photography, and normal SAP. Glaucomatous
eyes (n=38) had glaucomatous ONH damage and corresponding abnormal SAP defined as an abnormal
glaucoma hemifield test and pattern standard deviation (PSD) outside 95% normal limits (average PSD
greater than 8.0 dB). Retinal vascular caliber was measured using a previously established protocol
(Amerasinghe et al). Graders were masked to glaucoma status with the ONH removed from photos used
for analysis of central retinal artery equivalent (CRAE) and the central retinal vein equivalent (CRVE)
calibers.
Results: Average CRAE for glaucomatous eyes was 140 uM (SD=18) compared to 150 uM (SD=15) for
normal eyes. Average CRVE for glaucomatous eyes was 215 uM (SD=23) compared to 225 uM (SD=20)
for normal eyes. CRAE was statistically decreased for glaucomatous compared to normal eyes (t-test,
p=0.0017) with decreased CRVE for glaucomatous compared to normal eyes (t-test p=0.012).
Discussion: Glaucomatous ONHs had an average 6.7% decrease in arterial and 4.4% decrease in venous
vessel caliber compared to normal eyes. Glaucoma has been suggested to be associated with vasospasm
and other vascular risk factors. In addition, decreased optic nerve head perfusion has been suggested to
be a risk factor for the development and progression of glaucomatous damage. This study demonstrates
that vessel caliber, which can affect perfusion pressure and rates, is decreased in ONHs of glaucomatous
eyes.
Conclusions: Mean arteriolar caliber is significantly decreased in glaucomatous ONHs suggesting
glaucoma is associated with vascular changes.
References:
Amerasinghe N, et al. Evidence of Retinal Vascular Narrowing in Glaucomatous Eyes in an Asian
Population. IOVS 2008; 49;5397-5399.

Abstract.ControlNumber:250

Abstract.Title:Scanning Electron Microscopic Evaluation Of Morphologic Changes After Continuous
Versus Multipulse Yellow Laser Trabeculoplasty

PrimaryAuthor.AuthorBlock:

Jeremy B. Wingard, Kimberly V. Miller, Michael J. Pokabla, Korrinn Strunk, Jennifer L. Gray, Rocio
Bentivegna, Robert J. Noecker. UPMC Eye Center, Pittsburgh, PA, University of Pittsburgh, Pittsburgh, PA

Topic.Topic1:Surgery

Abstract.Abstract1:

Purpose: To evaluate changes in the trabecular meshwork (TM) morphology after continuous yellow
laser trabeculoplasty (YLT) versus a range of power settings of multipulse laser trabeculoplasty (MYLT).
Methods: Human cadaver eyes were obtained from autopsy and sectioned to enable direct laser
application to the TM. The Iridex IQ577 (577 nm) laser was used for all laser applications. Distinct
regions were treated with multiple, non-overlapping laser spots of the following types: (1) YLT (500-
1000 mW, 100 ms, 50 µm), (2) MYLT (2000 mW, 200 ms, 300 µm, 15% duty cycle), (3) MYLT (1500 mW),
(4) MYLT (1000 mW), (5) MYLT (500 mW), and (6) untreated control. Glutaraldehyde and phosphate-
buffered saline were employed to preserve each sectioned eye, and scanning electron microscopy was
performed to evaluate the TM.
Results: Definitive focal burns and coagulative damage were identified in the YLT treated TM, with crater
formation in the uveal meshwork. This appearance was similar to published results using the argon laser
(ALT).1 Although craters were not seen with MYLT, the higher energy settings (1500-2000 mW) did
create areas of thermal damage. When the lower energy settings (500-1000 mW) were used, the TM
morphology was indiscernible from the untreated control.
Discussion: The morphologic changes in the TM of cadaver eyes varied by the type of laser energy
delivered. Continuous YLT caused crater formation not seen even with the higher energy settings of
MYLT. At lower energies of MYLT, there was no morphologic evidence of any structural damage to the
TM. It appears that the multipulse technology, delivered in this case with a 15% duty cycle, effectively
limited tissue destruction from thermal damage.
Conclusion: MYLT may be a less destructive alternative for laser trabeculoplasty due to decreased
thermal damage.
References:
1. Kramer TR, Noecker RJ. Comparison of the morphologic changes after selective laser trabeculoplasty
and argon laser trabeculoplasty in human eye bank eyes. Ophthalmology 2001;108(4):773-9.

Abstract.ControlNumber:251

Abstract.Title:Changes In The Diagnostic Evaluation Of Patients With Open-angle Glaucoma From 2001-
2009

PrimaryAuthor.AuthorBlock:

Joshua D. Stein, Nidhi Talwar, Alejandra M. Laverne, Bin Nan, Paul R. Lichter. University of Michigan, Ann
Arbor, MI, University of Michigan School of Public Health, Ann Arbor, MI

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Purpose: To determine the extent by which new technology is affecting how clinicians are evaluating
patients with open-angle glaucoma (OAG).
Methods: An analysis of claims data for all enrollees with OAG (n=169917) age ≥40 in a national US
managed care network was performed to assess trends in visual field testing (VF), fundus photography
(FP), and ocular imaging (OI) from 2001-2009. Repeated measures logistic regression was performed to
identify differences in the odds of undergoing these procedures in 2001, 2005, and 2009 and whether
differences exist for patients under exclusive care by optometrists versus ophthalmologists.
Results: The odds of OAG patients undergoing VF testing decreased 35% from 2001 to 2005, 13% from
2005 to 2009, and 43% from 2001 to 2009. By comparison, the odds of undergoing OI increased 102%
from 2001 to 2005, 22% from 2005 to 2009, and 146% from 2001 to 2009. For patients cared for
exclusively by optometrists, the probability of undergoing VF testing decreased from 66% in 2001 to 44%
in 2009. For patients under the exclusive care by an ophthalmologist, the probability of VF testing
decreased from 65% in 2001 to 51% in 2009. The probability of undergoing OI rose from 26% in 2001 to
47% in 2009 for patients under the care of an optometrist and 30% in 2001 to 46% in 2009 for patients
receiving care by an ophthalmologist. By 2008, OAG patients cared for by optometrists had a higher
probability of undergoing OI than VF testing. Probabilities of undergoing FP were relatively low (15-24%)
for both provider types and did not vary much over the decade.
Discussion/Conclusion: From 2001-2009 there has been a dramatic rise in OI use coupled with a
substantial decline in VF testing. If OI is not as effective at detecting OAG or disease progression,
increased reliance upon this technology, in lieu of VF testing, may result in adverse patient outcomes.
Financial Disclosure: All authors have no relevant disclosures.

Abstract.ControlNumber:253

Abstract.Title:

An Analysis Of The Change In Anterior Chamber Depth Before And After Laser Peripheral Iridotomy

PrimaryAuthor.AuthorBlock:

Monika Singh, Shobit Rastogi, Douglas Lazzaro, Michael Ehrenhaus. SUNY Downstate Medical Center,
Brooklyn, NY

Topic.Topic1:Imaging of Anterior Segment

Abstract.Abstract1:

Introduction:
Angle-closure glaucoma often develops in eyes that are anatomically pre-disposed to it, i.e. narrow
angles. In order to prevent an attack of acute angle closure glaucoma, a procedure, laser peripheral
iridotomy (LPI) is performed. The goal of an LPI is to alleviate pupillary block and prevent angle closure.
This studied analyzed the changes in the anterior chamber depth in patients with narrow angles who
had undergone an LPI.
Methods:
The study was conducted prospectively at the Long Island College Hospital (LICH). Patients who were
scheduled to have an LPI done were consented and had Scheimpflug PentaCam photos taken before and
after the LPI. Scheimpflug Pentacam images, segments 13-17, from 152-183 degrees of the anterior
chamber were used for analysis. Both anterior chamber depth and volume were recorded.
A total of 53 eyes of 38 patients (ages 50-77, mean = 60) were enrolled in the study, after informed
consent was obtained.
Results:
The anterior chamber depth pre-LPI varied for the 53 eyes in our study from 1.13 to 4.00 mm (mean =
2.52 mm); post-LPI values ranged from 2-5.11 mm (mean = 3.13). There was a 0.6 mm increase in
anterior chamber depth on average. Anterior chamber volume also showed an increase, from 96.8 mm3
to 124.6 mm3 (mean = 27.8 mm3) between pre and post LPI. Further, IOP measurements, taken as part
of the standard ophthalmic exam, showed a decrease of 4 points, i.e. from 20 mm Hg to 16 mm Hg.
Discussion:
Till date, patients who have undergone a laser peripheral iridotomy have gonioscopy performed at
future visits to qualify the increase in anterior chamber depth. There is no standard accepted method to
quantify the objective increase in anterior chamber depth.
Conclusions:
The findings of our study validate the Scheimpflug Pentacam as a useful tool in monitoring patients who
have undergone laser peripheral iridotomy.
References:

Abstract.ControlNumber:254

Abstract.Title:

Is There An Association Between Exudative Age-Related Macular Degeneration And Open-Angle
Glaucoma?

PrimaryAuthor.AuthorBlock:

Tiffany N. Szymarek, Nidhi Talwar, Melissa Nika, Caroline Schmidt, Sayoko Moroi, Bin Nan, David Reed,
Joshua D. Stein. University of Michigan, Ann Arbor, MI

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: The purpose of this study is to determine whether an association exists between exudative
macular degeneration (AMD) and open-angle glaucoma (OAG).
Methods: Individuals were identified from a large US managed care network between 2001-2009, who
were ≥ 60 years and continuously enrolled for 3 to 5 years. ICD-9CM billing codes were used to identify
individuals with ≥ 1 diagnoses of exudative AMD or OAG. Logistic regression analysis was performed to
assess the relationship between exudative AMD and OAG adjusting for sociodemographic factors,
medical and ocular comorbidities. An additional analysis was performed on individuals with suspected
glaucoma to assess whether exudative AMD was associated with the conversion from suspected
glaucoma to OAG.
Results: Among 399,117 individuals who met inclusion criteria, there were 44,725 (11.2%) with OAG and
9,436 (2.4%) with exudative AMD. After adjusting for confounders, individuals with exudative AMD had
a 13% increased odds of OAG (p =0.0001, adjusted OR = 1.13, 95%CI [1.06-1.20]). Those with exudative
AMD had an 18% increased odds of converting from suspected glaucoma to OAG (p = 0.02, adjusted OR
= 1.18, 95% CI [1.03-1.36]).
Discussion: In this study, there appears to be an association between exudative AMD and OAG, which
supports previous comorbid association of these two major eye diseases in Medicare beneficiaries (1, 2).
Conclusions: Additional studies are needed to determine whether or not these two conditions share
some common physiologic and/or genetic risk factors.
References:
1. Zlateva GP, Javitt JC, Shah SN, Zhou Z, Murphy JG. Comparison of comorbid conditions between
neovascular age-related macular degeneration patients and a control cohort in the medicare population.
Retina. 2007 Nov-Dec;27(9):1292-9.
2. Lee PP, Feldman ZW, Ostermann J, Brown DS, Sloan FA. Longitudinal prevalence of major eye
diseases. Arch Ophthalmol. 2003 Sep;121(9):1303-10.

Abstract.ControlNumber:255

Abstract.Title:To Compare EyeCam With Gonioscopy For Evaluation Of The Anterior Chamber Angle.

PrimaryAuthor.AuthorBlock:

Sunita Radhakrishnan, Haiyan Wang, Terri D. Pickering, Andrew G. Iwach. Glaucoma Center of San
Francisco & Glaucoma Research and Education Group, San Francisco, CA, Glaucoma Research and
Education Group, San Francisco, CA, Glaucoma Center of San Francisco, San Francisco, CA, Glaucoma
Center of San Francisco & Glaucoma Reserach and Education Group, San Francisco, CA

Topic.Topic1:Imaging of Anterior Segment

Abstract.Abstract1:

Purpose: To compare EyecamTM (Clarity Medical Systems, Pleasanton) imaging with gonioscopy for
evaluation of the anterior chamber angle. The EyecamTM provides photographic images of the angle
and can be performed by a technician.
Methods: Charts of all patients who underwent EyeCam imaging at the Glaucoma Center of San
Francisco were reviewed. Patients were excluded if the interval between gonioscopy and EyeCam was >
3 years, if any laser or surgery was performed in the interval between gonioscopy and EyeCam or if
gonioscopy data was not available for all four quadrants. Only one eye per patient was included.
Gonioscopy grading was based on anatomical structure observed with the eye in primary gaze. EyeCam
images were also graded based on angle structure visible and the EyeCam grader was masked to
gonioscopy findings. Kappa statistic was used to evaluate the correlation between gonioscopy and
EyeCam imaging.
Results: 50 eyes (50 patients) were studied, the mean age was 57.8 ± 14.3 years and 52% were males.
Thirty four eyes (68%) had POAG or were glaucoma suspects and the remaining included 4 eyes (8%)
with pigment dispersion, 5 eyes (10%) with refractive error only, 3 eyes (6%) with exfoliation, 3 eyes
(6%) with PACG and one eye (2%) with inflammatory glaucoma. Disregarding scleral spur-ciliary body
mismatches, the agreement between EyeCam and gonioscopy by Kappa statistic was 0.74, 0.71, 0.77
and 0.74 in the inferior, superior, nasal, & temporal quadrants respectively. Sources of discrepancy
between the two techniques included incorrect angulation of the EyeCam probe during image
acquisition and incorrect interpretation of gonioscopy or EyeCam findings.
Conclusion: The EyeCam provided high quality documentation of the
anterior chamber angle appearance. In this group of mostly open angles, EyeCam performed by a
technician showed substantial agreement with gonioscopy. The EyeCam’s unique features may be
valuable in the setting of telemedicine as well as for patient and physician education.

Abstract.ControlNumber:256

Abstract.Title:Four Year Incidence Of Open-angle Glaucoma (OAG) And Ocular Hypertension (OHT) In
Latinos: The Los Angeles Latino Eye Study (LALES)

PrimaryAuthor.AuthorBlock:

Rohit Varma, Cathy Wu, Mina Torres, Brian Francis, Vikas Chopra, Betsy Nguyen, Stanley Azen.
University of Southern California, Los Angeles, CA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: Previous evidence from the LALES suggests that Latinos have a high prevalence of OAG,
comparable to that in African Americans. However, not data exist for the incidence of OAG in Latinos.
Furthermore, no data exist on the incidence of OHT in Latinos.
Methods: The LALES is a population-based study of primarily Mexican Americans in Los Angeles.
Participants underwent a baseline and 4-year follow-up examination including a Humphrey Visual
Field (SITA Standard), stereoscopic optic disc photography and Goldmann applanation tonometry.
Incident OAG was defined by the presence at follow-up of either characteristic optic nerve changes or
visual field loss or both in eyes in which these changes were not present at baseline. Similarly,
incident OHT was defined by the presence at follow-up of an IOP of 21mmHg or higher in eyes in
which it was lower than 21 mmHg at baseline. Frequency distributions and trend tests were
performed.
Results: Of the 6100 living persons examined at baseline, 4658 were examined at the 4-year follow-
up. The 4-year incidence of OAG was 3.45% in the first eye. There was an age-related increase in the
incidence of OAG (40-49 years old -1.66%, 80+ years old - 18.6%). In persons who had OAG in one eye
at the baseline examination, 21.5% developed OAG in the second eye at follow-up. The 4-year
incidence of OHT was 3.53% in the first eye. There was no age-related increase in the incidence of
OHTG (40-49 years old - 2.37%, 80+ years old - 2.04%). In persons who had OHT in one eye at the
baseline examination, 20% developed OHT in the second eye at follow-up.
Conclusion: Latinos have a high incidence of OAG and OHT. Compared to incidence in the first eye the
incidence of OAG and OHT in the second eye is 6 fold higher. There is an age-related increase in the
incidence of OAG but not for OHT.
Discussion: The incidence rates in Latinos are significantly higher than those observed in non-Hispanic
Whites in Melbourne and Rotterdam but lower than those in Barbados. Physicians should inform their
patients with unilateral OAG/OHT of the high incidence on OAG/OHT in the second eye. Given that
Latinos are the fastest growing segment in the US, programs targeted at Latinos would be helpful in
reducing the burden of OAG in the US.

Abstract.ControlNumber:257

Abstract.Title:Toward A Predictive Model For Detecting Non-adherence To Glaucoma Medications: The
Automated Dosing Reminder Study (ADRS)

PrimaryAuthor.AuthorBlock:

Dolly S. Chang, Harry A. Quigley, David S. Friedman, Travis C. Frazier, Michael V. Boland. Wilmer Eye
Institute, Johns Hopkins University, Baltimore, MD, Madigan Army Medical Center, Tacoma, WA

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Introduction: Prior work has identified risk factors for non-adherence with glaucoma medications. As
part of the Automated Dosing Reminder Study (ADRS), we asked questions and collected baseline
characteristics that might detect non-adherence with glaucoma therapy.
Methods: 323 patients treated with once daily prostaglandin therapy in a university-based glaucoma
practice were enrolled in the study. Subject use of medication was monitored electronically for 3
months. Multivariable regression was used to assess the association between baseline criteria and
adherence, adjusting for age, gender, race, and number of glaucoma medications prescribed.
Results: 19.5% of subjects used their prostaglandin drops less than 75% of the time. Younger age, non-
white race, single medication therapy, no prior eye surgery, no family history of glaucoma, and using
medications ≤ 1 year were factors significantly associated with poor adherence. Three questions were
also significantly related to non-adherence (p ≤ 0.001): 1) Over the past month, what percentage of your
drops do you think you took correctly? 2) Some days I forgot to take one of my doses of glaucoma
medications. And 3) What are the names of your glaucoma medications? We constructed a predictive
model including these questions and factors associated with poor adherence. The area under the
receiver operating characteristic curve was 0.87, indicating good discrimination.
Discussion: Patients in the poor adherence group took fewer drops than they reported (86% by report
vs. 47% as measured). Items in the questionnaire were highly specific but not sensitive. A possible
strategy to identify non-adherence is to administer a 3-item questionnaire for patients who were non-
white or without family history of glaucoma. If positive in 2 out of 3 questions, non-adherence can be
identified with a sensitivity of 69% and a specificity of 86%.
Conclusion: Combining clinical factors and the answers to some simple questions can assist clinicians in
identifying patients at risk of non-adherence.

Abstract.ControlNumber:258

Abstract.Title:Baseline Optic Nerve Topography and Retinal Nerve Fiber Layer Thickness Predict Visual
Field Progression in Glaucoma Suspect and Glaucomatous Eyes
PrimaryAuthor.AuthorBlock:

Mitra Sehi, Namita Bhardwaj, Maria C. Reyes, Yun Suk Chung, David S. Greenfield. Bascom Palmer Eye
Institute, Palm Beach Gardens, FL

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:

Purpose: To assess whether baseline optic nerve head (ONH) topography and retinal nerve fiber layer
thickness (RNFLT) are predictive of glaucomatous visual field progression in glaucoma suspect and
glaucomatous eyes.
Methods: Participants with ≥3 years of follow-up were recruited from the longitudinal Advanced
Imaging in Glaucoma Study. One eye per subject was enrolled. All eyes underwent standard automated
perimetry (SAP), confocal scanning laser ophthalmoscopy (CSLO), time-domain optical coherence
tomography (TDOCT) and scanning laser polarimetry using enhanced corneal compensation (SLPECC)
every six months. Progression was assessed using pointwise linear regression analysis of SAP sensitivity
values (ProgressorTM) and defined as significant sensitivity loss of ≥2 adjacent test locations in the same
hemifield at >1dB/yr at p<0.01. Cox proportional hazard ratios (HR) were calculated to determine the
predictive ability of baseline ONH and RNFL parameters for SAP progression using univariate and
multivariate models.
Results. Seventy-three eyes consisting of 43 glaucoma suspects and 30 glaucoma patients (mean age
63.2±9.5 years) were enrolled (mean follow-up 51.5±11.3 months). Four of 43 glaucoma suspects (9.3%)
and 6 of 30 (20%) glaucomatous eyes demonstrated progression. Mean time to progression was
50.8±11.4 months. Using multivariate models, the following parameters were predictive of SAP
progression (HR, 95% CI): abnormal CSLO temporal-inferior MRA classification (HR=4.2, p=0.02), SLPECC
inferior RNFLT per 1 µm thinner (HR=1.23 [1.0 to 1.4], p=0.02), and TDOCT inferior RNFLT per 1 µm
thinner (HR=1.11 [1.04 to 1.20], p=0.001).
Discussion. Our results emphasize that optic nerve and RNFLT abnormalities are useful adjuncts for
prediction of subsequent SAP progression and should be used in conjunction with established clinical
and demographic risk factors.
Conclusion. Abnormal baseline ONH topography and reduced RNFL are predictive of SAP progression in
glaucoma suspect and glaucomatous eyes.

Abstract.ControlNumber:259

Abstract.Title:Hyperlipidemia, Statin Use and Open-angle Glaucoma

PrimaryAuthor.AuthorBlock:

Paula Anne Newman-Casey, Nidhi Talwar, Bin Nan, Paul R. Lichter, Julia E. Richards, Joshua D. Stein.
University of Michigan, Ann Arbor, MI, University of Michigan School of Public Health, Ann Arbor, MI

Topic.Topic1:Pharmacology
Abstract.Abstract1:

Introduction: The purpose of this study is to determine whether hyperlipidemia or treatment of
hyperlipidemia with HMG coA-reductase inhibitors (statins) affects the risk of developing open-angle
glaucoma (OAG).
Methods: All individuals age 60 years or older continuously enrolled for at least 2 years in a large
national US managed care network from 2001-2009 were identified. ICD-9CM billing codes were used to
identify individuals with hyperlipidemia. Statin use was quantified for each enrollee using outpatient
pharmacy records. Cox regression analyses were performed to assess the relationship between statin
use, hyperlipidemia, and the development of OAG, with adjustment for sociodemographic factors,
medical and ocular comorbidities. Additional models were performed to determine whether statin use is
associated with development of suspected glaucoma and the conversion from suspected to diagnosed
OAG.
Results: Of the 682,525 enrollees who met the inclusion criteria, 524,109 (77%) had hyperlipidemia and
302,157 (44%) had taken statins for ≥1 month. After adjustment for confounding factors, the hazard of
developing OAG decreased 0.4% (adjusted HR = 0.996, CI (0.994-0.998) p=<0.001) for every additional
month of statin consumption, and the hazard of progressing from suspected glaucoma to OAG
decreased 0.5% (adjusted HR = 0.995 (0.993-0.998), p= 0.0005) for every additional month of statin
exposure. There was no significant difference in the hazard of developing suspected glaucoma (adjusted
HR = 0.999, CI (0.998-1.001) for each additional month of statin use.
Discussion: This study supports others that have shown that statins may play a role in reducing the
development of OAG or the progression from suspected glaucoma to OAG.
Conclusion: This study offers insights into why some studies in the literature support a protective role
for statins and other studies do not.

Abstract.ControlNumber:260

Abstract.Title:Choroidal Thickness Measured By SDOCT Depends On Age, Axial Length, CCT And Diastolic
Perfusion Pressure, But Not Degree Of Glaucoma Damage

PrimaryAuthor.AuthorBlock:

Eugenio Maul, Harry A. Quigley. Wilmer Eye Institute, Baltimore, MD

Topic.Topic1:Imaging of Optic Nerve/Structural Assessment

Abstract.Abstract1:


Introduction: To measure macular and perpapillary choroidal thickness and to determine parameters
associated with it in glaucoma patients.
Methods: Spectral domain optical coherence tomography (SDOCT) scans were obtained to estimate
average choroidal thickness in a group of normals, glaucoma suspects and glaucoma field loss
patients. Average thickness was calculated from enhanced depth SDOCT images. Glaucoma was
defined by disc and field criteria. The most affected eye was analyzed for comparisons across
individuals, while right/left and upper half/lower half comparisons were made to compare thickness
against degree of visual field damage.
Results: 74 glaucoma/suspect patients were imaged. The choroidal-scleral interface (CSI) was
visualized in 86% and 96% of the macular and peripapillary scans, respectively. In multivariable linear
regression analysis, the macular choroid was significantly thinner in association with 4 features:
longer eyes (22 μm per mm longer *95% CI: -33, -11+), older individuals (31 μm thinner per decade
older [95% CI: -44 -17+), lower diastolic ocular perfusion pressure (26 μm thinner per 10 mmHg lower
[95% CI: 8, 44+), and thicker central corneas (6 μm per 10 μm thicker cornea *95% CI: -10, 0]).
Peripapillary choroidal thickness was not significantly different between glaucoma and suspect
patients. Thickness was not associated with damage severity as estimated by visual field mean
deviation or nerve fiber layer thickness, including comparisons of right to left eye or upper to lower
values.
Discussion: Age, axial length, CCT, and diastolic ocular perfusion pressure are significantly associated
with choroidal thickness. Degree of visual field damage was not consistently associated with choroidal
thickness.
Conclusion: Choroidal thickness is a dynamic variable, affected by blood pressure and intraocular
pressure.
References: Yin Z, Vaegan, Millar T, Beaumont P, Sarks S. Widespread choroidal insufficiency in
primary open-angle glaucoma. J Glaucoma 1997;6(1):23-32.
Fujiwara T, Imamura Y, Margolis R, Slakter J, Spaide R. Enhanced depth imaging optical coherence
tomography of the choroid in highly myopic eyes. Am J Ophthalmol 2009;148(3):445-50.

Abstract.ControlNumber:262

Abstract.Title:Clinical Findings In Eyes With Long Anterior Zonule (LAZ) Trait

PrimaryAuthor.AuthorBlock:

Daniel K. Roberts, Jacob Wilensky. University of Illinois at Chicago, Chicago, IL

Topic.Topic1:Other

Abstract.Abstract1:

Introduction: Long anterior zonule (LAZ) trait is a condition that occurs in up to 2% of individuals over
60 years of age. It is associated with a pigmentary dispersion-like phenotype, but with shallow
anterior chambers. We conducted a case control investigation of LAZ patients.
Methods: 47 LAZ patients and 47 age, sex and race matched controls were examined. Examinations
included ocular and medical history, refraction, slit lamp exam, applanation tonometry, corneal
pachymetry, gonioscopy and A-scan biometry.
Results: The patients were 67.1 years of age. 43 of the patients were female. 50% of the LAZ patients
had Krukenberg spindles. The patients were more hyperopic (+1.85 vs -0.01 diopters, p<.01) and had
shorter eyes (23.07 vs 23.84mm, p<.01) than the controls. Six of the LAZ patients had had laser
iridotomies performed because of narrow angles because of narrow angle or positive provocative tests.
Discussion: Patients with LAZ present with some clinical findings (e.g. Krukenberg spindles) that are
seen in pigmentary glaucoma, but differ from it in that they are older, predominently female and are
hyperopic.
Conclusions: LAZ has some of the same morphologic features as pigmentary glaucoma, but is quite
different in other aspects, although they both may be associated with clinical glaucoma
References: Roberts DK, Winters JE, Castells DD et al. Pigmented striae of the anterior lens capsule
and age-associated pigment dispersion of variable degree in a group of older African-Americans: an
age, race, and gender matched study. Int Ophthalmol 2001; 24(6):313-322.

Abstract.ControlNumber:263

Abstract.Title:Natural History of Glaucoma Drainage Implants and Corneal Transplants

PrimaryAuthor.AuthorBlock:

David Chu, Michael Banitt, Anne Ko, William Feuer, Joyce Schiffman, Richard K. Lee. Bascom Palmer Eye
Institute, Miami, FL, New York Eye and Ear Infirmary, New York City, NY

Topic.Topic1:Surgery

Abstract.Abstract1:


Purpose: Failure of trabeculectomy glaucoma surgery is often followed by glaucoma drainage implant
(GDI) surgery to control intraocular pressure (IOP). Secondary glaucoma after penetrating
keratoplasty (PKP) and corneal decompensation after GDI placement are post-surgical complications
with significant morbidity. The purpose of this study is to report the clinical course of post-
trabeculectomy eyes requiring aqueous shunt implant surgery and subsequent corneal
transplantation.
Methods: A retrospective review of post-trabeculectomy eyes which underwent GDI and subsequent
PKP was performed. Eyes with corneal edema prior to GDI surgery, and those with GDI-corneal touch
were excluded. Factors evaluated included: cornea and glaucoma diagnoses, visual acuity, intraocular
pressure, corneal graft survival, surgical timing, post-operative complications, and need for additional
surgery.
Results: Twenty-four eyes with glaucoma were studied (54% with an initial diagnosis of primary open
angle glaucoma, 21% with pseudoexfoliation glaucoma). The average time between trabeculectomy
failure to first GDI was 44.5 (±41.1) months. The average time between last GDI to first PKP was 36.8
(±27.4) months. No significant association with number of GDIs, number of prior intraocular surgeries,
or GDI quadrant was observed. Corneal decompensation occurred at IOPs between 0 and 23 mmHg,
suggesting endothelial dysfunction due to GDI, not damage from markedly elevated IOP. Within the
first 5 years after first PKP, 20% of GDI failed and 73% of corneal grafts failed.
Conclusion: Corneal decompensation after GDI occurs even with controlled IOP. The number of
glaucoma surgeries was not significantly associated with GDI to PKP time. Corneal grafts did well in
the first two years after PKP, but had a significant number of failures in subsequent years, even with
relatively good IOP control.

Abstract.ControlNumber:264

Abstract.Title:The Different Spectrum Of Glaucomas In Various Asian American Populations

PrimaryAuthor.AuthorBlock:

Shan C. Lin, Michael Seider, Melike Pekmeczi, Pai Peng, Chris Sales, Roland Lee. UCSF Ophthalmology,
San Francisco, CA, Shin-Kong Hospital, Taipei, Taiwan

Topic.Topic1:Epidemiology of Glaucoma/Clinical Trials

Abstract.Abstract1:

Purpose: To assess the types and distribution of glaucoma types among Asian Americans.
Methods: Clinic-based population studies were conducted in retrospective fashion to assess the
distribution of different types of glaucoma among Chinese Americans, Vietnamese Americans, Japanese
Americans, and Filipino Americans. All patients had full ophthalmic exam including gonioscopy, optic
disc examination, and visual field testing.
Results: Asian Americans have a diverse spectrum of glaucoma types that can have very different
distributions among different groups. Chinese Americans have a high proportion of narrow or closed
angles (57%) among their glaucoma and suspect subjects. Vietnamese Americans have a high proportion
of closed-angle and mixed-mechanism glaucoma (41%) among all their glaucoma cases. Normal tension
glaucoma encompasses the majority of glaucoma (69%) among Japanese Americans. In a clinic
population, Filipino Americans have a higher proportion of closed angle glaucoma (8%) among their
glaucoma cases than whites (0%). Filipino Americans also had a higher normal tension glaucoma
proportion (47%) than whites (27%) (p=0.02).
Discussion: Chinese and Vietnamese Americans have high proportions of closed-angle glaucoma.
Japanese Americans have mostly normal tension glaucoma. Filipino Americans have a moderate
proportion of closed-angle glaucoma and a large proportion of normal tension glaucoma.
Conclusions: In summary, the distribution of glaucoma types varies substantially among Asian
Americans.

Abstract.ControlNumber:265

Abstract.Title:Hypotonous Maculopathy: Outcomes After Bleb Revision

PrimaryAuthor.AuthorBlock:

Elena Bitrian, Diem Bui, Suyeon Ahn, Joseph Caprioli. Jules Stein Eye Institute, Los Angeles, CA

Topic.Topic1:Surgery

Abstract.Abstract1:
Purpose: To report the long-term efficacy and safety of bleb revision for hypotonous maculopathy.
Methods: This is a non comparative retrospective case series of hypotonous maculopathy that
underwent a primary bleb revision between June 1999 and June 2010 by a single surgeon. Hypotonous
maculopathy was characterized by low IOP, loss in visual acuity and retinal striae. Patients with less than
3 months of follow-up or that underwent a prior bleb revision were excluded. Surgery involved resection
of necrotic conjuctiva, resuture of the scleral flap with 10-0 nylon, use of pericardium patch graft in
some cases and conjunctival advancement.
Results: Thirty-three eyes of 33 patients (age 66.65 ± 14.40 years) were followed for an average of 2.74
± 3.07 years (range 3 months - 9.5 years). Forty-five percent were female and 3 (9%) presented with
choroidals as well as macula striae. After bleb revision, the mean baseline intraocular pressure (IOP)
increased from 3.16 ± 1.94 mmHg to 11.71 ± 5.24 mm Hg at the last follow-up (P<0.001). Visual acuity
also improved from 0.30 ± 0.21 to 0.53 ± 0.23 (P<0.001). Seventy-five percent of patients were on no
antiglaucoma drops at last follow-up. Four cases (12 %) required a second bleb revision to resolve the
hypotonous maculopathy.
Discussion: Surgical repair for hypotony maculopathy was associated not only with improvement in IOP,
but also in visual acuity, both at short and long term of follow-up.
Conclusion: Bleb revision is an effective procedure with good long-term control of IOP and improvement
of visual acuity in eyes with hypotonous maculopathy.
References:
1.Outcomes of surgical bleb revision for complications of trabeculectomy. Radhakrishnan S, Quigley HA,
Jampel HD, Friedman DS, Ahmad SI, Congdon NG, McKinnon S. Ophthalmology. 2009 Sep;116(9):1713-8.
2.Outcome of bleb revision using scleral patch graft and conjunctival advancement. Au L, Wechsler D,
Spencer F, Fenerty C. J Glaucoma. 2009 Apr-May;18(4):331-5.
3.Bleb revision for hypotony maculopathy after trabeculectomy. Bashford KP, Shafranov G, Shields MB. J
Glaucoma. 2004 Jun;13(3):256-60.

Abstract.ControlNumber:266

Abstract.Title:

New Imaging Techniques To Study Transparent Tubules (TT) Spanning Schlemm’S Canal (SC), Structures
Subject To Disruption By SC Surgery.

PrimaryAuthor.AuthorBlock:

Murray Johnstone, Kevin Curtiss, Daniel Possin, Jing Huang, Mark Slaba. University of Washington,
Seattle, WA

Topic.Topic1:Trabecular Meshwork/Outflow

Abstract.Abstract1:

Introduction: Transparent tubes (TT) that span across SC represent likely conduits for aqueous flow. SC
surgery disrupts the TT. We developed new techniques to image the TT to better study their function.
Methods: M. Nemestrina (5), 80-power dissecting microscope (DM), Healon™, Karnovsky’s fixative, 150
u viscoelastic cannula, fiber optic light source, light, phase contrast, Nomarsky (DIC) & confocal
microscopy. Each eye (10 total) divided into 4 quadrants, viscoelastic introduced into SC in each limbal
quadrant to dilate SC followed by fixation. SC lumen was examined in each radial 500 μ segment thus
surveying the entire 360° of SC in each eye. At the DM with coaxial light, cylindrical structures spanning
SC were transparent, becoming visible only with oblique illumination. Further imaging of cylindrical
structures was done by DM (168 sections), phase contrast (19), DIC (35 stacks with a total of 5,120 1-2 μ
sections) and confocal fluorescence (4 stacks, a total of 330 1 μ sections).
Results: Eye #8 OD & OS: 77 segments were examined & 91 cylindrical structures spanning SC
photographed. Ave. structures/segment: OD 1.33, OS 1.07. Structure frequency: 0 (15 segments), 1 (40
segments), 2 (16 segments), 3 (5 segments) and 4 (1 segment). Eye #8 OS; structures per quadrant: SN
(8), IN (13), IT (14), ST (12). Computer generated 360° rotating 3D projections were obtained in 3
confocal stacks. The 3D projections demonstrated cylindrical structures arising from SC inner wall in a
funnel shape to then cross SC with their distal lumen opening at collector channel ostia.
Conclusions: Transparent tubes spanning SC become visible with the new imaging techniques. The TT
appear capable of acting as normal aqueous conduits but are subject to disruption by SC surgery.




Abstract.ControlNumber:267

Abstract.Title:Influence Of Cup-to-Disc Ratio On Ab Interno Trabeculotomy Outcomes
PrimaryAuthor.AuthorBlock:

Steven D. Vold. Boozman-Hof Eye Clinic, P.A., Rogers, AR

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction: To analyze the impact of cup-to-disc ratio on the safety and efficacy of ab interno
trabeculotomy using the Trabectome in glaucoma patients.
Methods: A prospective, non-randomized, observational, comparative cohort study of 1604 Trabectome
patients was followed for at least 6 months. The patients were stratified into 2 groups based on their
cup-to-disc ratios. Group 1 has patients with cup-to-disc ratios less than or equal to 0.8. The patients
with cup-to-disc ratios greater than 0.8 are in group 2. The main outcome measures were intraocular
pressure, glaucoma medications and occurrence of any secondary surgeries.
Results: At 6 months post-operatively, the IOP in group 1 patients (n=835) was reduced 28% from
24.8±8.0 mmHg to 16.4±4.2 mmHg (p<0.01), and mean number of glaucoma medications was reduced
24% from 2.71±1.33 mmHg to 1.93±1.38 mmHg (p<0.01). At 6 months post-operatively, the IOP in group
2 patients (n=769) was reduced 23% from 22.8±7.2 mmHg to 15.9±4.1 mmHg, and mean number of
medications dropped 23% from 2.90±1.21 mmHg to 2.08±1.37 mmHg (p<0.01). The percentages of
secondary surgeries in the groups were 12% and 16% respectively.
Discussion: Ab interno trabeculotomy has been demonstrated to be effective and safe in patients with
open angle glaucoma. However, little is known about whether the severity of glaucoma might impact
postoperative outcomes of Trabectome surgery. This study evaluates the hypothesis that patients with
an earlier stage of glaucoma might respond more favorably than those with more advanced
glaucomatous disease.
Conclusions: The drop in IOP and glaucoma medications was significant in each of the two groups. Group
1 had the highest percentage drop in IOP and glaucoma medications at 6 months postoperatively from
baseline levels.
References: Minckler DS, Baerveldt G, Alfaro MR, et al. Clinical results with the Trabectome for
treatment of open-angle glaucoma. Ophthalmology. 2005 Jun;112:962-7.

Abstract.ControlNumber:269

Abstract.Title:The Prevention Of Ocular Scarring Following Glaucoma Filtering Surgery Using The
Monoclonal Antibody Lt1009 (sonepcizumabtm)in a Rabbit Model.

PrimaryAuthor.AuthorBlock:

Zachary Lukowski, Jeff Min, Ashley Beattie, Craig Meyers, Monica Levine, Glenn Stoller, Gregory Schultz,
Don Samuelson, Mark Sherwood. University of Florida, Gainesville, FL, LPath, Inc., San Diego, CA,
University of Florida, Gainesville, FL, University of Florida, Gainesville, FL

Topic.Topic1:Pharmacology
Abstract.Abstract1:

Introduction: Excessive scarring leading to failure of the filtering bleb continues to be a major problem
following glaucoma filtration surgery. This paper examines the anti-fibrotic effects of the anti-S1P
monoclonal antibody LT1009 (SonepcizumabTM) in prolonging bleb survival in a rabbit model of
glaucoma filtering surgery.
Methods: The frequency of LT1009 dosage was determined initially using an ELISA assay measuring
LT1009 eye tissue retention in 6 New Zealand White (NZW) rabbits. A further 21 NZW rabbits underwent
glaucoma filtering surgery. Bleb tissues were observed and compared clinically and histologically. The
duration of bleb elevation was compared among LT1009, balanced saline solution (BSS) negative
control, and 0.4 mg/ml mitomycin-C (MMC) positive control.
Results: The mean duration of bleb survival was 28.5 +/- 8.5 days for rabbits receiving injections of
LT1009, 21.0 +/- 5.6 days for those receiving injections of BSS, and 33.8 +/- 5.6 days for rabbits receiving
MMC. ANOVA statistical analysis with post-hoc testing suggests a statistically significant trend of
improvement in bleb duration for LT1009 when compared to BSS controls. Non-painful, upper eyelid
edema was noted following five injections of LT1009 which resolved over a 10-day period. MMC eyes
developed avascular conjunctivas with areas of thinning and sparse cellularity, while the conjunctiva of
LT1009 and BSS eyes remained relatively normal.
Conclusions: The monoclonal antibody LT1009 demonstrated a longer duration of bleb elevation than
BSS control without adverse conjunctival effects associated with MMC. However after multiple doses
LT1009 use was associated with short-term upper eyelid edema.

Abstract.ControlNumber:270

Abstract.Title:Comparison Of Aqueous Humor Proteins From Patients With Glaucoma Or Cataract

PrimaryAuthor.AuthorBlock:

Darrell WuDunn, Susanne Ragg, Melissa Key, Sarita Tony, Madhurima Bhattacharjee, Louis Cantor, Chi-
Wah Yung, Yara Catoira-Boyle, Shailaja Valluri, Linda Morgan, Joni Hoop. Indiana University,
Indianapolis, IN, Indiana University, Indianapolis, IN, Persistent Systems Limited, Pune, India

Topic.Topic1:Other

Abstract.Abstract1:

Purpose:
To identify aqueous humor proteins that distinguish glaucoma from cataract.
Methods:
Aqueous samples were obtained from eyes during glaucoma or cataract surgery. Liquid chromatography
tandem mass spectrometry (LC-MS/MS) provides great depth of protein coverage, while protein
antibody arrays were used for lower abundance proteins. Glaucoma and cataract samples were age and
gender matched. For LC-MS/MS, aqueous samples were depleted of albumin and immunoglobulins.
Tryptic peptides were analyzed on a linear ion-trap (LTQ) mass spectrometer. After peptide
identification, peptide-level quantitative information was combined into protein summaries based on
reference sequence databases. For protein antibody arrays, aqueous samples were incubated on
customized glass slides spotted with antibodies to 50 proteins previously identified in aqueous humor. A
mixed effects model fit with restricted maximum likelihood estimation was used to test the differential
abundance of each protein.
Results:
From 21 cataract and 20 glaucoma samples LC-MS/MS detected 82 proteins with high confidence, all of
which had been previously found in aqueous humor. For most proteins, mean intensity levels between
glaucoma and cataract samples differed by no more than 10%. Ten proteins were present at significantly
(unadjusted) different levels (10-15%) in glaucoma samples including alpha-2 macroglobulin, which has
been reported to be higher in glaucoma aqueous. However, after adjustment for multiple comparisons,
no differences were significant. In protein antibody array analysis (21 glaucoma and 21 cataract
samples), although no proteins were significantly different after multiple comparison correction, at least
seven proteins showed potential for further study.
Discussion:
In these preliminary studies, 132 proteins were compared. Although no proteins were significantly
different between cataract and glaucoma samples after multiple comparison correction, several
candidates merit further study using larger sample sizes.
Conclusions:
Aqueous humor protein profiles from glaucoma and cataract patients are similar although subtle
differences would not be detectable in these small studies.

Abstract.ControlNumber:272

Abstract.Title:Intraocular Pressure Control in Patients Undergoing ExPRESS Miniature Glaucoma Implant
With and Without Cataract Extraction

PrimaryAuthor.AuthorBlock:

Regine M. Pappas, Leslie S. Jones, Oluwatosin Smith. Pinnacle Eye Center, Melbourne, FL, Howard
University, Washington, VA, Glaucoma Associates of Texas, Dallas, TX

Topic.Topic1:Surgery

Abstract.Abstract1:INTRODUCTION: This study evaluated the effectiveness and rate of complications of
the Ex-PRESS Mini Glaucoma Shunt in reducing IOP when performed with cataract surgery and alone.
Methods: This retrospective study was conducted at Pinnacle Eye Center, Howard University Hospital,
and the University of Mississippi Medical Center. A chart review of consecutive eyes having undergone
Ex-PRESS Mini Glaucoma Shunt implantation between January 2008 to December 2008 was performed.
The following preoperative data were recorded: best corrected visual acuity, IOP, and number of
preoperative glaucoma medications. Operative data including surgeon, technique, size of shunt, use of
antimetabolites, and occurrence of complications were also recorded. Postoperative data collection
included IOP measured and number of eye medications recorded at day 1, week 1 and months 1, 3, 6, 9
and 12. Success was deemed as IOP &lt;21 mmHg. Failure was defined as eyes that required re-
operation for glaucoma. Results: A total of 180 eyes of 174 consecutive patient records were reviewed.
There were 59 % female (n=102) and 41% male patients (n=72). The mean age was 71 years. All
surgeries were performed by a single surgeon at each center with use of Mitomycin C and placement of
the shunt under a partial thickness sclera flap. Forty-eight eyes underwent combined cataract extraction
with Ex-PRESS implantation and 126 eye had Ex-PRESS implantation alone. Average preoperative IOP
was 23 mmHg for all eyes. The average postoperative IOP for eyes undergoing cataract and Ex-PRESS
was 13 mmHg and 12 mmHg in the Ex-PRESS only group at postoperative day 1; 11 mmHg for both
groups at postoperative day 7; 13 for both groups at the 6,9, and 12 month time points. There were few
complications with 4 eyes experiencing worsening of cataract, 3 bleb leaks, 4 subsequent bleb revisions,
3 subsequent Baerveldt aqueous tube shunts. Discussion: The Ex-PRESS implant was equally effective
when performed with cataract surgery or alone. Few complications were noted in either group.
Conclusion: Implantation of Ex-PRESSS mini shunt was effective and safe with control of IOP as long as
12 months following the procedure when performed with cataract extraction and alone.

Abstract.ControlNumber:274

Abstract.Title:Performance of the Visual Field Index (VFI) Near the Advanced Field Loss Mean Deviation
Value.

PrimaryAuthor.AuthorBlock:

Dennis Mock, Elena Bitrian, Lauren Doss, Anne Coleman, Kouros Nouri-Mahdavi, Joseph Caprioli. UCLA,
Los Angeles, CA

Topic.Topic1:Perimetry and Functional Testing

Abstract.Abstract1:

Purpose: To assess the change in the sensitivity of the visual field index (VFI) across the perimetric
advanced field loss mean deviation of -20.0 dB.
Methods: We used data collected from the Advanced Glaucoma Intervention Study database (AGIS) and
selected eyes from patients whose visual field (VF) time series had two consecutive VFs within 1.5 years
and whose MD values had changed from less than to greater than -20.0 decibels or vice versa. The visual
field index (VFI) and mean deviation (MD) values are calculated by StatPacTM.
Summary and Results: The eyes (n=23) with pairs of consecutive visual field readings had an average
time period difference of 0.67 + 0.7 years. In none of the cases did the patient’s age (from the 1st to the
2nd test) extend into the next age-matched normal decile. Therefore any change in the total deviations
(TD) values reflects the absolute change in threshold sensitivity and thus we expect the relative change
in VFI to systematically correspond to the relative change in TD (or MD). The average difference
between the expected change in MD and the actual difference was 4.1 + 1.9 dB.
Discussion: A method to estimate the rate of visual progression in glaucoma, the visual field index (VFI)
has been reported by Bengtsson and Heijl (2008). For MD values > -20.0 decibels, the VFI is calculated by
selecting the test point locations from the pattern deviation (PD) probability map and using the total
deviation (TD) values; otherwise the TD values are strictly used.
Here we detect a systematic bias in the VFI when shifting from a MD greater than -20.0dB to a MD less
than -20.0 dB. In all the cases, the number of assessed test point locations increased due to the nature
of how PDs are derived from TDs and in numerous cases the entire visual field was selected after the
change point was reached.
A linear extrapolation of the VFI has been suggested to represent a global visual field rate of
progression; however any such use of information to infer the global change in the threshold
sensitivities must consider model consistency or the absent of calculation anomalies that may occur at
the boundary where the nature of the formula is changed.

Abstract.ControlNumber:275

Abstract.Title:Visual Acuity Recovery After Slit Lamp Revision of Trabeculectomy

PrimaryAuthor.AuthorBlock:

Emily Cook, Alfred Solish. Southern California Glaucoma Consultants, Pasadena, CA

Topic.Topic1:Surgery

Abstract.Abstract1:

Introduction:
Visual acuity (VA) recovery after trabeculectomy requires approximately 2 months. Slit lamp revision
(SLR)doesn't create new astigmatism, considered a major cause of slow recovery of VA following
trabeculectomy, so recovery after an SLR should be more rapid.
Methods:
The charts of 47 patients and 48 eyes which underwent SLR were reviewed for VA and intraocular
pressure (IOP) at 1 week, 3 weeks, 6 weeks, and 6 months.
Results:
At 6 months, 33 of 48 eyes (68%) had equal or better VA than at time of procedure.
Of the 15 with lower VA, 12 had regained their VA in the first 6 weeks postoperatively but had later
decreased. Their average starting IOP was 23 mmHg (range 3-50), with an average 3.25 lines lost (range
1-8), and average drop in IOP of 8.25 mmHg (range -28-48).
Of those 33 eyes which did not lose VA, the average start IOP was 16.3 mmHg (range 5-28), with an
average 1.39 lines improvement in acuity (range 0-5), and the average drop in IOP was 2.95 mmHg
(range -10-18). The average time taken to recover acuity was 12 weeks (range 1-25 week)
Of the 13 patients (27%) who started with an IOP greater than 21 mmHg, 8 (61%) had lower VA at 6
months than at the date of procedure. Their average loss in VA was 1.84 lines (range -8-4) and average
change in IOP was 13.5 mmHg (range 6-48).
Discussion:
The reason for loss of VA after SLR can be hypothesized to be from many sources similar to
trabeculectomy, from hypotony maculopathy to cataract progression2. While not statistically significant,
recovery of visual acuity averaged longer than the reported 2 months of recovery after trabeculectomy.
Pre-procedure IOP over 21 mmHg seemed to increase the chances of VA loss. VA loss was also
associated with larger drops in IOP.
Conclusions:
From the data presented here, it appears that the clinician must be aware that return of full pre-
procedure VA cannot be assumed. Recovery time should not be presumed more rapid than
trabeculectomy.
References:
1. Seah SK, Prata JA Jr, Minckler DS, Lee MB, Baerveldt G, Lee PP, Heuer DK. Visual recovery after
trabeculectomy. J Glaucoma. 1995 Aug;4(4):228-34.
2. Costa VP, Smith M, Spaeth GL, Gandham S, Markovitz B. Loss of visual acuity after trabeculectomy.
Ophthalmology. 1993 May;100(5):599-612.